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ANTISEPTIC SUEGEEY
ANTISEPTIC SURGERY
ITS PRINCIPLES, PRACTICE, HISTORY
AND RESULTS
W. WATSON CHEYNE, M.B., F.K.C.S.
ASSISTAXT-SURGEON TO KING'S COLLEGE HOSPITAL
DEMOXSTRATOU OF SURGICAL PATHOLOGY AT KING'S COLLEGE
Mit^ Illustrations
LONDON
iSMlTH, EI.DEK, & CO., 15 WATEKLOO PLACE
1882
[All riijhts reserveil ]
I
PREFACE.
The interest which Antiseptic Snrgery has awakened'
throughout the profession has led to many j)ublic debates
and to the accumulation of a great mass of literature on
the subject. The time seems now to have come for a
detailed account and discussion of the whole matter, and
it is with the view of furnishing such an account that
the present volume has been published. The question
might have been dealt with in two ways ; either by the
discussion of the present standpoint of the principles and
practice of Antiseptic Surgery, with but little reference
to former literature ; or, as I have attempted to do, by
tracing in addition the development of its theory and
practice, and following out and criticising the various
steps by which the present state of knowledge on the
subject has been reached. The former mode might no
doubt have produced a shorter work, but it could not have
been made complete in the present transitory state of our
knowledge, and, taken alone, it would have necessarily
raised side issues confusing to readers unacquainted with
tlie earlier literature. I have therefore, in addition to
tlie discussion (jf the present state of knowledge on the
subject, tried to trace out its development, and 1 have
done this the more readily because it seems to me that
when an attempt is made, almost for the first time, to
X riiEFACE.
discuss fully a new department of science, the work of
those who have chiefly helped by experiment or criticism
to build it up should be acknowledged and properly
estimated. Such a way of treating the subject will
perhaps also supply a want to those who have not the
time nor the opportunity of searching out the literature
for themselves. Among other facts which have been
brought forward here I may draw special attention to the
folio wino;, which I think have been now made certain: —
Fermentations in wounds occur as the result of the
entrance of particles — micro-organisms — from without ;
a variety of methods of treatment may be grouped under
the heading ' Antiseptic treatment ' ; lives are saved in
proportion to the asepticity of the wound, and, when
the wound is kept aseptic, infective diseases more
especially are avoided ; the aseptic or Listerian method
prevents the development of micro-organisins and the
occurrence of fermentation in wounds.
Portions of this work have been previously published.
Some investigations on micro-organisms in wounds and
on temperature after operations formed part of my essay
Avhich gained the Syme Surgical Fellowship of the
University of Edinburgh in 1877. I have since that
time repeated and extended these investigations. In
the essay to which was awarded the Boylston Medical
Prize and the Boylston Gold Medal ^ of the Harvard
' By an order adopted in 1826 the Secretary of the Boylston Prize
Committee was directed to publish annually the following votes : —
1st. That the Board do not consider tliemselves as approving tlie
doctrines contained in any of the dissertations to which pi-eniiiinis may be
adj udgt'd.
2\\(\. That in case of publication of a successful dissertation, tlio autlior
be considered bound to print tlie above vote in connection therewilli.
TREFA CE. xi
University, United States, in 1880, 1 discussed the various
methods of Antiseptic Surgery and the best modes of
apply mg them to practice. And, in 1881, the council
of the College of Surgeons of England awarded me the
Jacksonian prize for a discussion of the history, prin-
ciples, practice, and results of Antiseptic Surgery. This
work is the outcome and development of these essays.
The drawings in this book (both the woodcuts and
the plates) have been made by Mr. Edgar Thurston,
to whom I am much indebted for the great pains which
he has bestowed m their preparation. Mr. Groves also
kindly took some photographs, from which certain of
the woodcuts have been drawn. Dr. Heron has ren-
dered me great assistance in revising the proof-sheets
and in preparing the Index.
In dedicating this work to Mr. Lister I have
attempted to acknowledge my great indebtedness
to him.
W. WATSON CHEYNE.
0 Old Cavendish St., \V.
October 1881.
CONTENTS.
CHAPTER I.
THE PARTICULATE THEORY OF FERMENTATION.
ON THE FERMENTATION OF BOILED SUBSTANCES.
TAGR
Definition of putrefaction and fermentation — Chemical fermentations —
Living ferments — Various views on fermentation — Lavoisier — Fa-
broni — Tlienard — \ppert — Gay-Lussac's experiments and conclusions
— Caignard-Latour — Schwann, heated air inert — Schulze — Ure and
Helmholtz, nascent oxj^gen inert — Liebig's views— Review of the
subject — Schroeder and Dusch, filtered air inert — Schroeder, ozone
inert — Schroeder's final views — Pasteur's researches — Lister — Roberts
— Tyndall^My own results, carbolised air inert — Conclusions as to
the cause of the fermentation of boiled substances .... 1
CHAPTER II.
THE PARTICULATE THEORY OF FERMENTATION {continued).
ON THE FERMENTATION OF UNBOILED SUBSTANCES.
{jVAiiti yncc—Gaif-Liiasa' — Van tier Brocck— Pasteur — Boberts; blood —
Van (Icr Broech — Pasteur — Bvrdoii- Sanderson — Lister — 3Iy own re-
sults; unboiled urine — Van der Broeelt — Pasteur — Lister — My own
results— Boberts — Cazeneure and Liron; milk — Hoppe-Seyler — Bo-
hrrts — LAster — My own, experiments ; egg albumen — Van der Liroerk
— Gayon — BobeHs — My own experiments; vegetable tissues — Boberts;
animal tissues — Billroth — 'Hegel — Burdon-Sanderson — My own ex-
periments— C'Mene and Ewart — Meissner — General review of the facts
— Behaviour of fluids and tissues in the living body— Principles of
aseptic surgery ;{()
CHAPTER in.
ASEPTU; SUR(;EKY — materials EMPLOYED,
Problems to be solved in order to kcoi) a wound aseptic : Carbolic acid -
Carbolic lotions - Pure earbolic aeid — Solution in methylated spirit —
rarbol/e oil - Carbo/ie aeid and ylyrerine : Spray fjroducers: Catgut
CONTENTS.
— Carholisrd caffpit- Mr. Litsfcr'a earholtsi'd chromic catf/nt — Dr. J\fac-
Ewcn's chromic catf/iit — Caft/iit troiir/h a)id j/ochct caxc: Carbolised silk:
Protective: Carbolic gauze — Composition — Method of preparation — Yon
lirun\'< gauze : Macintosh : Sponges : Boracic acid — Boracic lotion —
Boradc lint — Boracic ointment : Salicylic acid —SalicijUc acid, cream.
■ — Salici/Uc ointment : Chloride of zinc : Iodoform : Carbolised cotton
wool 52
CHAPTER IV.
ASEPTIC SURGERY [confinned).
Example of an aseptic operation : Purification of the skin — Fingers —
Instruments: Spray — Precautions— Probable errors, and mode of re-
medying them : Guard : Ligature of arteries : Drainage of wounds —
India-rubber tubes — Catgut drains —Horse hair — Decalcified bone tubes
(Neuber's and MacBwen's) : Sutures: Button stitches — Stitches of re-
laxation— Stitches of coaptation — Aseptic strapping — Protective : DeeiJ
dressing : Loose gauze : Gauze dressing : Elastic bandage. Changing
THE DRESSINGS — Time — Method. Treatment of ulcers : Purifica-*
tion of the sore : Boracic dressing : Boracic and salicylic ointment :
Boracic poultice 67
CHAPTER V.
ASEPTIC SURGERY (cOUtintieJ).
Special dressings : Head dressfiiigs : Neck dres.tings : Bread dresKinfiK —
Abscess of mamma — Excision of mamma alone — Excision, of mamma,
and axillary glands : Axillary dressings : Dressings on the limhs :
Dressings for psoas abscess : Lumbar abscess : Hip-joint abscess :
Dressings in cases of hernia a7id operations on the scrotum: Excisions
of joints. AsejDtic treatment of abscesses. Chief points to be con-
sidered in opening abscesses — Method of opening abscesses — Drainage
of absresscs— After-treatment of abscesses — Empyema — Perineal and
anal abscesses. Treatment of wounds produced accidentally : Problem
to be solved— Purification of wound — Further treatment of the n'ound.
Special wounds : Compound fractures : Wounds innolring tendons,
nerves, <^'c. : Wounds of joints : Compound fr act w'es of the skull: Pene-
trating wounds of the thorax: Wounds of the abdomen. Putrid sinuses
and wounds. Treatment cf burns. Treatment of gangrene. Treat-
ment of na;vi and varicose veins ........ 0(5
CHAPTER VL
ASEPTIC SURGERY — MODIFICATIONS.
Country practice : How to dispense with the spray during the operation —
and during the aft:;-: '^-eatment: How to render the ilreasings less fre-
CONTEXTS. XV
PAOK
quent. Is the aseptic method applicable in war ? 3rr. Lister' s<
snggestians : Esmarch's X}liui : Jiei/Jier's method. Development of
Aseptic Surgery in Mr. Lister's hands : Compound fractures— Pvre
carbolic acid — Formation of crust — Carbolic putty — Lead 2)laster —
Imc plaster, syringing wounds with carbolic lotion, protect'n^e, catgut
ligatm-es, method in 1870 — Present method in the main introduced in
1871 — Further introduction of wet gauze, steam spray, elastic bandages:
abscesses — Method of opening them under carbolic oil : wounds . .120
CHAPTER Vll.
ASEPTIC SURGERY {concluded).
other methods of carrying out Aseptic Surgery. Substitutes for carbolic
acid: Salicylic acid : Thymol: Acetate of Alumina : Eucaltjptus oil.
Aseptic surgery by filtration of the air. Subcutaneous surgery . . i.SO
CHAPTER Vni.
THEORIES OF SPONTANEOUS GENERATION, HETEROGENESIS
AND ABIOGENESIS.
Principles on which other methods of Antiseptic Surgery act. Organisms
are always present in fermenting liquids : their significance. Theory
of the origin of organisms independently of a parent. Theories of
Needham and Buffon : Needham's proofs. Spallanzani"s experiments :
Needham's objections : Spallanzani's replies. Schulze's experiments.
Schwann — Schroeder and Duscli — Schroeder. Doctrine of Hetero-
genesis. Poiichet's work : his method of test ing the matter : proofs
that the source of the organisms in infusions is neither the air, water,
nor the putrescible substances : modes of repeating Schulze's and
Schwann's experiments : examination of dust. Criticism of his re-
sults. Pasteur's experiments : results with ordinary fluids : introduc-
tion of dust into sterilised fluids : results with milk and alkaline
fluids : the cause in the air which gives rise to the growth of organ-
isms is particulate : Pasteur's cultivating fluid : estimate of Pasteur's
work. Pouchet's reply : New experiments— Criticism of tliese . . 14")
CHAPTER IX.
SPONTANEOUS GENERATION {continued).
The experiments of Jeffries Wyman : explanation of the results : VVyman's
views on the subject. Dr. Uastian's views: Cases in which it is still
possible that abiogcnesis may occur : Growth in vacuo— Bastian's ex-
periments—my own results — Cohn's facts — Dj- Roberts's ohjection.s,
the walls of the ve.s.sels remain impure — Basfian's reply — Objections
to the latter — Graitlmiscn's experiments — Pau i.i-rt's results wiili
CONTENTS.
compressed air — Pouchct looks on a vacuum as preventing spontaneous
generation — Paul Bert's results with rarefied air — Ur. Bastian does not
always get positive results : Experiments in airless and hermetically
sealed flasks raised to a high temperature — Objections— Prof. Huxley's
and Dr. Sanderson's statements — Ray Lankester's results — Hartley:
expei'imen-ts with alkaline fluids — Roberts's counter-experiment. Mr.
Lister's experiments. Experiments by Roberts and Tyndall . .172
CHAPTER X.
SPONTANEOUS GENERATION (conchtded).
Facts with regard to unboiled fluids and tissues : Mr. Lister's facts
with regard to milk : my own experiments with animal tissues.
Present state of the question — Dr. Bastian's latest standpoint : Lie-
big's doctrine. Can organic molecules derived otherwise than from
pre-existing bacteria give rise to bacteria ? Firstly, there is nothing
unreasonable in looking on these particles as bacteria or their germs:
seeds carried by air : excessive minuteness of the germs of bacteria :
Mr. Lister's experience with micrococci. Secondly, there is no direct
evidence that organic molecules not derived from bacteria can give
rise to bacteria : facts with regard to unboiled fluids and tissues —
conclusions from these facts : Paul Bert's experimenTs : Cazeneuve
and Livon: Pasteur: Dr. Bastian. Thirdly, there is no evidence
that active organic molecules (chemical ferments, &c.) can resist
heat more than living things can : effects of heaJt on ptyalin, pepsin,
•&c. : my own case of difficulty in sterilising mil'k : Wyman's fact as
to an alga living at 208 F I94
CHAPTER XT,
RELATION OF MICRO-ORGANISMS TO FERMENTATION.
■Summary of what has preceded with reference to fermentation. Relation
between ' vital ' and ' chemical ' fermentations : theories of fermen-
tation. Liebig's views. Alcoholic fermentation : Paxte^ir'' » experiments
tnid eonchishms. Rfsnmc. Butyric fermentation. Formation of pig-
iiTicnt by bacteria. Schroeter : Cohn. Viscous fermentation. Lactic
fermentation : Panteur : Lister. Other fermentations, especiaJly tJbe
putrefactive: Levi aire ; Cazeneuve and Liron:: Paul Bert. C'onclu-
■sions ............. 20;'i
(mAPTER Xn.
RELATION -OF MI€RO-ORGANISMS TO THE FLUIDS AND TISSUES
OF THE LIVING BODY.
Propo.sed mode of cnquir;- — Does the aseptic met liod prevent putref^ac-
tion? Does it exclude organisms from wound.s? Kanke's results:
CONTENTS.
Klebs' objection: Ranke's reply: Demarquay : Fischer: Schiiller :
my own method — Results in aseptic wounds — Results in wounds
treated otherwise — Koch's method of staining pus — Results in cases
not treated aseptically — Examples of complete exclusion of organ-
isms in aseptic cases — Examples of the entrance of micrococci in
aseptic cases — Detiuition of micrococci — Distinctions between micro-
cocci and bacteria. Are organisms present in the healthy living
body ? — ' Bistournage.' Are organisms present in the body in states
of disease ?— Experiments with ammonia, phosphorus, &c. — The
healthy blood and tissues can destroy organisms — Relation of organ-
isms to abscesses. How do micrococci enter aseptic wounds 1 Car-
bolic lotion a salficient germicide ; Spray, its value — Stimson's
experiments ; Gauze dressing as a protection against entrance of
organisms ; Carbolic acid as a germicide in albuminous fluids ; Rela-
tions of micrococci aud bacteria to fluids containing carbolic acid.
Conclusions . . ......... 225
CHAPTER XIII.
ANTISEPTIC SURGERY.
Complete definition of antiseptic surgery. Varieties of antiseptic sur-
gery. Treatment by Antiseptics : Carbolic acid — objections to it :
Chloride of zinc : Boracic acid : Sulphurous acid : Chlorinated Soda :
Alcohol — Hutchinson's method : Terebene and Sanitas — Bilguer's
method — Neudorfer's salicylic powder. Free drainage as an an-
tiseptic 3IETHOD. Irrigation and immersion. Open method:
Modes in which it acts antiseptically : Bartscher and Vezin's method :
Burow's method: Rose's modification. Healing by scabbing:
Methods of forming a crust : Bouisson's ventilation method : other
modes. Cuerin's cotton-wool dressing. Modes in which
THE destructive ACTION OF THE TISSUES ON BACTERIA IS AS-
SISTED. Wliy does not fermentation always occur in the blood in
wounds in wliich organisms are present ? Best practical methods.
Conclusions 265
CHAPTER XIV.
HISTORY OF ANTISEPTIC SURGERY.
Practice of the ancient writers. Attempts of the ancients to secure im-
mediate union of wounds. Pare and Paracelsus : Delacroix : Arcjeus :
Progress of wound treatment in the sixtcentli century. Seventeenth
century: Magatus: Wiseman: Colbatch : Progress in the seventeenth
century. Eighteenth century and the early jiart of the nineteenth :
Boerhaave : Col dc Villars : Heister : Bilguer : Benjamin Bell : Abcr-
nethy : John Hunter's objections to the views of Bell and Abernethy :
John Bell : opinion and practice of other surgeons : Conclusions : Von
Kern . . 290
CONTENTS.
CHAPTER XV.
HISTORY OF ANTISEPTC SURGERY (continued).
I'AOB
History of the various methods. Incubation : Gu3'^ot. Subcutaneous
surgery, preliminary attempts : Stroraeyer : DielTcnbach : Jules
Guerin : Langenbeck : Other authors. Occlusion : Jules Guerin :
Chassaignac — Eochard's remarks: Pansement ouate — Alphonse
Guerin, method and results — Oilier. Substitution of various gases
for air: Demarquay and Leconte. Open Method: I'Sartscher and
Vezin: Burow: Humphre}-. Healing by scabbing: John Hunter:
Xeudorfer : Bennion : Lister : Bouisson : Bonnet, kc. Irrigation
and the water-bath : early history : Josse : Berard : Mayor: Amussat :
Langenbeck: Valette 317
CHAPTER XVI.
HISTORY OF ANTISEPTIC SURGERY (conckuhd).
Use of antiseptics: Alcohol — older WTiters — Nelaton — Hutchinson: Glyce-
rine—Demarquay : Chlorine: Chloride of zinc: Iodine: Iodoform:
Chlorate of Potash : Perchloride of iron, &c. : Coal tar — Corne and De-
raeaux — Report of the commission : Coal tar saponine — Lemaire — his
views on putrefaction : Carbolic acid — Lemaire — Lemaire"s position
n regard to Aseptic Surgery — Lister : Further phases in the historjr of
this subject : Objections to Mr. Lister's claim as originator of the
Aseptic method — Simpson — Neudorfer. Modifications of the method.
Su.bstitutes for carbolic acid. Objections to the Aseptic method . . 347
CHAPTER XVII.
RESULTS OF ANTISEPTIC SURGERY.
Chief points for consideration. How far do the various methods prevent
fermentations in wounds ? How to ascertain the true value of any
individual method. The value of the various methods in guarding
against infective disease: meaning of the term 'infective disease'
Relations of Aseptic Surgery to infective disease. 3/r. Lufrr's remdtn
iv fllaariow. The recent Glasgow .tfatiaficK. Mr. Lixter's resvlts in
Edinlmrf/h ; re.snlts in sejftic and asej)tio ca^es — 3/r. Sjfcnce's jwactice
— Mr. Slime's results — Mr. Lister\'< results at Kinff's Cnlle/je Hospital :
— Volkmann — Nmshauni — Socin — Saxtorph — Esmareh. — lluetcr —
Czeriiy — Lucas- Cliamqnonnix-re — Gross — LHievant — Panas — Schede—
Reyher — Spencer Wells — Keitli^Thornton. TliicrscVs results with
salicylic acid. Thymol. The relations of other forms of Antiseptic
Surgery to these diseases — Treatment hy Antiseptics — Beyher — lAstcr
— Nvlaton — JTutchinson. Occlusion — Jules Gverin — Alphonse Guerin.
Treatment hy irrigation and mater hath — Langcnheck — Valette. Open
CONT'ENTS. xix
PAGE
Method — Barischer and Vezin — Bvrmv — Kr'onlein. Results where no
antiseptic measures were adopted — Billroth — Malyaigne — Paul —
Holmes — Erich&en. Eesults of cleanliness — Mo Vail — Bardenheuer . 365
CHAPTER XVIII.
RESULTS OF ANTISEPTIC SURGERY {continued).
General considerations. Wounds of, and operations on, healthj* joints.
Method of treatment adopted in these cases. Definition of the term
'Aseptic course': Example. Wounds of healthy joints. Operations
on healthy joints. Objections to the value of these cases : reply. In-
cisions into joints affected with synovitis. Incisions into joints af-
fected with pulpy degeneration of the synovial membrane — a without
suppuration, b with suppuration. A''oliimann's results : Max Schede :
Paul Barth : Saxtorph : Piechaud : Nussbaum : Albert : Hueter :
Letievant : Kraske : Eeyher: Bergmann. Comparison of Pieyher's
results with those obtained during the Crimean war, and with Heint-
zel's. Treatment bj' irrigation. Necessity for observing the minutest
precautions as shown by Mr. Lister's case. Piesults of removing
foreign bodies from joints without aseptic precautions : Larrej^ :
Speuce : Paget 417
CHAPTER XIX.
RESULTS OF ANTISEPTIC SURGERY {continued).
Compound fractures. Differences between those produced accidentallj^
and those caused by the surgeon : treatment and after-progress of each
class. Tables of accidental compound fractui-es treated by Mr. Lister:
thigh; leg; liutner us ; forearm ; skull; summary of results. Tables
of compound fractures produced intentionally bj' Mr. Lister ; femur ;
leg ; clavicle ; humerus ; forearm ; lower jaw. General summary of
Mr. Lister's results. Mr ^pence's results. Other operations on bones
by Mr. Lister. MacEwen's osteotomies : Volkmann : Max Schede :
Bardenheuer : MacCormac. Combined aseptic results: Results br-
other methods . Volkmann and Fraenckel : Holmes : St. Thomas's
IIosjDital. Rej'her's results in war. Open method: Kronlein. Septic
methods 461
CHAPTER XX.
RESULTS OF ANTISEPTIC SURGERY {continued).
Abscesses connected with di-sease of the vortebne. Best situation for
opening psoas abscesses : best time for opening them : after-treatment
and after- progress. Table of Mr. Lister'.s results : general summary
and remarks on these cases. Comparative statistics are wanting. Sir
James Paget 's views . . . 'Al
XX CONTENTS.
CHAPTER XXI.
RESULTS OF ANTISEPTIC SURGERY (concluded).
PAGE
General consideration of the results. Results of the various methods in
saving life. Results in avoiding infective disease. Cleanliness : defi-
nition of the term : Mr. Savorj-'s definition and method : cleanliness
has not abolished infective disease even in healthy hospitals : cleanli-
ness is a complex method : infective disease may appear even in the
best hygienic conditions. The source of infective disease. Conclu-
sions as to the value of the various methods in preventing infective
disease. Deaths from prolonged suppuration after chronic abscesses,
compound fractures, &c. Operations on weak or diseased individuals
are rendered possible by the aseptic method. Operations otherwise
iinjustifiable,but nevertheless necessary for the recovery of the patient,
may be safely done by the aseptic method. The patient may be made
a more useful member of society: joint cases : tenotomy, &c. : com-
pound fracture : dangers of operations of convenience. Local results
of wounds treated aseptically : absence of pain, inflammation, &c. :
experiments of Yeo and Ferrier : organisation of blood-clot, catgut,
sloughs, &c. Histological details of the process : Tillmann's experi-
ments. Temperature in aseptic cases : contrast with septic cases.
Local and constitutional course of cases not treated aseptically. Objec-
tions to aseptic surgery: carbolic acid poisoning: the surgeon is said
to neglect the constitutional state of the patient: expense: trouble :
necessity for the spray. Conclusion : great principle of wound treat-
ment is Rest . 540
Index 603
LIST OF ILLUSTRATIONS.
1. .Schwann's method of admitting heated air to putrescible fluids . . 7
2. Schroeder and Dusch's apparatus for supplying filtered air . .13
3. Pasteur's flask with the bent neck 16
4. Door of Mr. Lister's hot box 18
5. Mr. Lister's hot box 18
6. Mr. Lister's large double-necked flasks 19
7. Method of filling these flasks 20
8. Mr. Lister's arrangement to protect fluids in liqueur glasses from dust 21
9. Mode of filling Mr. Lister's liqueur glasses ...... 21
10. Dr. Roberts's bulbs (copied from Roberts) , 23
11. Prof. Tyndall's pure chamber (copied from Tyndall) . . . .24
12. Dr. Roberts's experiments with grape juice (from Roberts) . . 33
13. Pa.steur's method of obtaining fresh blood (from Pasteur) . . .34
14. Beaker containing unboiled meat and a putrescible fluid . . .46
15. Hand spray producer 54
16. The ordinary steam spray producer . 54
17. Steam spray producer, showing the lamp at present in i;se . . . 55
18. Large steam spray producer with double nozzle for ovariotomy, kc. . 56
19. Trough for catgut 59
20. Lister's pocket catgut holder 59
21. Machine used in the Glasgow Royal Infirmary for manufacturing
gauze 63
22. Porcelain trough containing instruments .soaking in carbolic lotion , 70
23. General arrangement of surgeon, assistants, towels, spray, &c., in an
operation performed with complete aseptic precautions . . .71
24. To .show the arrangement of towels, &c., in a large operation . . 72
2'>aMcth()(\ of tving vessels in dense tissues ...... 75
xxii LIST OF ILLUSTRATIONS.
25/'.Anotlier method of tying vessels in dense tissues (from Esmarch) . 76
26. Ordinary oblique-ended drainage-tube ready for use . . . .77
27. Drainage-tube with masses of gauze in the loops of tliread . . 77
28. Incision for inguinal hernia, stitched, showing tlie position of the
drainage-tube at the outer angle of the wound . . . .78
20. Sinus forceps ^9
.30. Catgut drain ready for insertion 80
31. Operation for stretching the sciatic nerve 82
32. The same wound stitched 83
33. Method of preparing a horse-hair drain for re-introduction . . 84
3-1. Lead buttons for deep stitches 85
35. Wound after removal of mamma and axilliary glands, stitched . 86
36. Excision of the hip-joint 88
37. Dressing in a case of psoas abscess opened above Poupart's ligament 90
38. Method of changing a psoas abscess dressing 92
30. General arrangement of dressings on the neck . .... 97
40. To show the arrangement of the turns of bandage on the head, seen
from above 98
41 . Dres.sing applied in a case of abscess of tlie mamma (breast dressing
No. 1) 98
42. Breast dressing No. 2 98
43. Dressing after excision of the mamma 99
44. Dressings applied after excision of mamma and axillary glands, to
show the arrangement of the dressings and bandages . . . 100
45. Binder applied outside the dressing represented in tig. 44, so as to
keep the parts and dressing at rest ...... 101
46. Dressing in cases of operation on tlie axilla alone .... 102
47. Dressing in a case of psoas abscess opened above Poupart's ligament,
seen from the front 103
48. Psoas abscess dressing (fig. 47), seen from behind .... 104
49. Dressing in a case of lumbar abscess, seen from behind . . . 101
50. Dressing in a case of hip-joint abscess, with elastic api^lied . . 105
51. Deeper part of the hernia and scrotal dressings 106
52. Dressing in a case of operation for hernia, or on the scrotum on the
left side, showing the arrangement of the dressing and elastic
bandage 106
53. Dressing in hernia cases or in operations on the scrotum, showing
the arrangement of the bandages in the perineum. (Seen from
below) 107
54. Si^lint for excision of knee, read}' for application .... 108
LIST OF ILLUSTRATIONS. xxiii
nr,. PAGE
5. Splint applied in a case of excision of the knee ..... 108
56. Two forms of sharp spoon.s, a large round one and a .small oval one . 117
57. Esmarch'.s first dressing for the wounded in battle (from MacCormac) 121:
58. Schulze's method of demonstrating that organisms are derived from
the air and do not originate spontaneou.sly in liquids . . . 150
59. Pouchet's mode of repeating Schulze's experiment (from Pouchet) . 156
60. Another mode adopted by Pouchet for testing Schulze's views (from
Pouchet) 156
61. A simple mode of repeating Schulze's experiments (from Pouchet) . 161
62. Pasteur's mode of introducing dust into flask containing calcined air 165
63. Another mode of repeating Schulze's experiment (from Pouchet) . 169
64. Bacillus subtilis ; without spores; with spores in the rods; free
spores; x 600 (after Cohn) ........ 180
65. Deposit in rennet, consisting of a mass of micrococci and spores of
bacilli, X 600 (after Cohn) 180
66. Dr. Roberts's experiment with alkaline fluids ..... 192
67. Torula cerevisiaj (after Pasteur) 210
68. Pasteur's experiment on unboiled grape juice ..... 210
69. Bacillus subtilis, x 650 (after Cohn) 212
70. Pigment producing organisms ........ 213
71. Bacterium lactis in pairs and chains . . . . . . .216
72. Flask containing cultivating fluid inoculated from a wound . . 231
73. Thiersch's ichampagne bottle irrigator . 273
7-1. Arrangement for irrigation in the upper limb (after Esmarch) . . 274
75. Arrangement for irrigation in the lower limb (after Esmarch) . . 275
76. Apparatus for continuous immersion (after Esmarch) . . . 275
77. Temperature chart from a case of operation for fracture of the
patella. (No. 21, p. 434) 421
Temperature charts of Mr. Lister's cases of wounds and operations
on joints (i.-xvii.) 438, 439
78. Temperature chart from a case of compound fracture in which the
attempt to eradicate the causes of fermentation was unsuccessful,
and which therefore became a septic case. (No. 26, p. 472) . . 463
79. Temperature chart from a case of compound fracture which followed
anasopticcour.se. (Case 23, p. 472) 4f,4
Temperature charts of Mr. Lister's cases of compound fracture
(xviil.-xxx.) 482, 483
Temperature charts of IMr. Lister's cases of compound fracture
(xxxi.-L.) 500, ,501
Temperature charts of cases of psoas and lumbar abscess (li.-
LXVli.) 534,535
xxiv LIST OF ILLUSTRATIONS.
FIG. I'AGE
80. Temperature cliart. from a case of MacEvven's operation for double
genu vulgum ........... 576
81. Temperature chart from a case of compound fracture, in which there
was great difficulty in retaining the fragments in position. (Case
27, p. 472)
82. Temperature chart from a case where the ankle-joint was incised in a
hajmophilious patient, and where hfemorrhage recurred several
times. (Case 16, p. 430) 581
83. Temperature chart from the case of removal of loose cartilage from
the knee-joint, in which fermentation occurred. (Case 22, p. 434) 582
84. Temperature chart from a case of operation for recent fracture of the
patella. (Case 15, p. 430) 582
Temperature charts of septic cases 584
Temperature charts of aseptic cases 585
ANTISEPTIC SUEGEEY.
CHAPTER I.
THE PARTICULATE THEORY OF FERMENTATION.
ON THE FERMENTATION OF BOILED SUBSTANCES.
Definition of putrefaction and fermentation — Chemical fermentations — Living
ferments — Various views on fermentation — Lavoisier — Fabroni — Thenard
— Appert — Gay-Lussac's experiments and conclusions — Caignard-Latour —
Schwann, heated air inert — Schulze — Ure and Helmholtz, nascent oxygen
inert — Liebig's views — Review of the subject — Schroeder and Dusch,
filtered air inert — Schroeder, ozone inert — Schroeder's final views — Pas-
teur's reseai'ches — Lister — Roberts — Tyndall — My own results, carbolised
air inert — Conclusions as to the cause of the fermentation of boiled sub-
stances.
The term ' septic ' so much used in surgery at the present day
is derived from the Greek word (X7]ittlkos, which means some-
thing that causes putrefaction, the verb (ji!]itw signifying to
cause to rot, to make putrid. An 'antiseptic' is therefore,
according to this derivation, something w^hich acts against the
causes of putrefaction, and ' Antiseptic Surgery ' is surgery
directed not against its effects but against its caitses. In deal-
ing, then, with the subject of antiseptic surgery, we must first
enquire what is putrefoction, and how is it brought about ?
Putrefaction is now held to be a form of fermentation ac-
companied by the development of offensive odours, and fermen-
tation may be defined as ' a new arrangement of the elements of
an organic compound (often with the assimilation of the ele-
ments of water), and the consequent formation of new products.'
(Fownes.)
Changes coming under the nbove definition of fermentation
B
2 THE PARTICULATE THEORY OF FERMENTATION.
have been long known as the result of what is termed Catalysis.
Of this perhaps the best example is the change effected in
Amygdalin by the action on it of Emulsin. As a result of the
contact of these two bodies in presence of water, the amygdalin
is broken up into various products, of which the chief are
hydrocyanic acid and oil of bitter almonds. This decomposition
of amygdalin is, however, not effected by combination with
emulsin, for the latter remains unchanged, although its presence
is necessary for the chemical action. Similar fiicts are known
with regard to the Pepsin of the gastric juice, the Ptyalin of
saliva, the pancreatic ferment, &c. But although these ferments
undergo little or no change, yet nevertheless it has been clearly
proved that they have not the jwwer of self-multiplication.
Hence these ferments generally receive the name of ' chemical '
ferments.
There is, however, another class of ferments which possess
this power of self-multiplication in a remarkable degree. An
instance of this may be given in the alcoholic fermentation.
Here a minute piece of yeast is introduced into grape juice, or
into a sugary solution, and as a result fermentation soon sets in,
and goes on slowly till the sugar is decomposed. If we compare
this process with the former we see two marked points of
difference ; in the first place, in the former the change is rapid
and more or less instantaneous; in the latter it progresses
slowly and steadily, and requires much more time for its com-
pletion. In the former there is no increase in quantity of the
ferment ; in the latter the increase is very marked, and when
the fermentation has gone on for some time the minutest
portion of the fermenting substance added to unfermented
material of like composition produces in it a similar series
of changes ; and this multiplication of the ferment goes on
continuously whenever it is brought in contact with fresh
material. As this power of multiplication is a property of living
things, the term ' vital ' is usually applied to this class of
ferments.
In one point the ' chemical ' ferment is allied to the ' vital '
ferment. It is not a substance as yet formed by the "chemist.
It is the product of living cells ; and it is quite possible that
the yeast plant may act in the same way as the salivary or
THE FERMENTATION OF BOILED SUBSTANCES. 3
peptic cells, viz. by excreting a ferment which produces the
change in the fermentescible substance, this ferment in neither
case possessing the power of self-multiplication. In the case of
the salivary ferment the cells which produce it are an integral
part of a complex organism, and cannot live apart from the body ;
hence the ptyalin, introduced into starch, does not increase in
amount. On the other hand, the yeast plant is an independent
cell, and grows free in the fermenting fluid, and it is to the
growth and multiplication of these living cells, and not to an
increase in quantity of the chemical ferment as such, that the
multiplication of the fermenting power is due.
In the putrefaction of discharges in wounds we have to deal
with a ferment belonging to the same class as the alcoholic fer-
ments— with a ferment capable of multiplication, which acts
slowly and steadily, not suddenly. We must therefore enquire
a little more fully into the nature of this class of ferments, into
theii- origin and history, in order to obtain some principles to
guide us in attempting to prevent their action.
In reviewing the history of this subject, the first research of
any consequence which it is necessary for us to consider is that
of Gay-Lussac* Previous to the publication of this paper at-
tempts had been made by Lavoisier, Fabroni, and Thenard
to give some explanation of the process of fermentation.
Lavoisier's work was in the main carried out with the view
of ascertaining the changes which a fermenting liquid under-
goes.^ He did not attempt to assign a definite cause for the
process.
Fabroni,^ writing on the subject of the alcoholic fermentation,
concluded that fermentation was a decomposition of one sub-
stance by another, 'just as a carbonate is decomposed by an
acid, or sugar by nitric acid. The substance which decomposes
sugar is a vegeto-animal substance. It is contained in certain
utricles in the grape. When the grape is crushed this material,
which is of the nature of gluten, mixes with the sugar in the
juice, and as soon as these two substances come into contact,
effervescence or fermentation commences just as occurs in every
• Annates de Cliinrie, Ixxvi. 1810.
^ J'JUtiindit de CMmic, i. 2nd ed.
^ Annalrs de Chimtr, xxxi. 1799.
4 THE PARTICULATE THEORY OF FERMENTATION.
other chemical process, as, for instance, when an acid and a
carbonate are mixed in the same vessel.'
Some years later, but ignorant of Fabroni's views,
Thenard published a research on alcoholic fermentation,' in
which he showed that gluten had no power whatever of causing
the fermentation of sugar. He observed that during the pro-
cess of fermentation, a deposit occurred which had the power
of inducing a similar change in a fresh saccharine liquid. This
substance was apparently the same in a great variety of liquids
of different chemical composition, and it presented characters
similar to those of yeast. Thenard states that he was unable
to determine whether this substance was formed in the course
of the fermentation, or whether it was in solution at the com-
mencement and became deposited as a result of the changes
which occurred. He, however, inclines towards the latter
view.
Gay-Lussac was led to make his investigations by studying
the procedure of M. Appert for preserving vegetable and animal
substances.^ Appert's method consisted in placing the materials
to be preserved in bottles, very closely corked. These bottles
were exposed to the temperature of boiling water for a longer
or shorter period of time. They were then packed up and kept
for use. There can be no doubt as to the efficiency of this
method, for in Appert's work certificates are furnished by
several scientific commissions, containing such names as Gay-
Lussac, Bordel, &c.
Gay-Lussac noticed that, though the sul^stances so prepared
could be preserved unaltered for an indefinite period so long
as the vessels were kept thoroughly closed, yet, as soon as
the vessels were opened, and more especially if the substances
were decanted into other vessels, their contents underwent
fermentative changes.
To ascertain why this occurred, he took a flask of grape-juice
which had been preserved for a year unaltered, and which was ac-
cordingly quite limpid. Having opened the flask he poured its
contents into another vessel, which he closed very accurately
and kept at the temperature of 15° to 30° C. Eight days later
' Atuudcs de ChhnU; xlvi. ISOiJ.
^ The Art of Preserving Animal and Vegctuhlc Suhstanees.
GAY-LVSSACS EXPERIMENTS. 5
the juice had lost its transparency, fermentation had become
established, and it soon became an alcoholic fluid. A second
vessel containing gi'ape-juice, prepared by Appert's method,
was kept at the same temperatm-e and in the same place, but
unopened. This remained pure. This latter flask, the neck of
which had been drawn out and sealed, was now taken, and
a deep notch having been made with a file, its neck was
plunged into mercury and then broken off. A portion of
the contents was then introduced into a bell-jar containing no
oxygen, and a second portion into one containing a small quan-
tity of that gas. The first remained without change for forty
days, while the second underwent fermentation very rapidly.
In the latter flask all the oxygen had disappeared, but much
more carbonic acid in proportion had been produced. Gay-
Lussac therefore concluded that, although oxygen is necessary
to initiate the fermentation, yet it is not essential for its con-
tinuance. The same results were obtained when currant-juice
or freshly prepared gi'ape-juice were used. Gay-Lussac further
found that, if this juice after being transferred from one vessel
to another were again heated after secure corking, it could
again be preserved for an indefinite time. He observed that
during the boiling the fluid lost its transparency and a deposit
took place. He came to similar conclusions as to the necessity
of oxygen for the initiation of fermentative processes, in the case
of the putrefaction of meats, &c., preserved according to Appert's
method,
Gay-Lussac concludes from his experiments that oxygen is
necessary for the commencement of the fermentation ; that
this oxygen combines with some substance in the fermentescible
fluid, thus producing the ferment, which can then act without
further oxygen ; that the effect of the heat in Appert's method
is to decompose any combination already formed, and to make
the oxygen which is present unite to form some substance which
is not a ferment ; that the product of this union with oxygen
is the deposit which is seen to occur on heating these fluids.
1 [e however recognises that fermentation is still a mysterious
process, since it occurs slowly and not immediately like other
chemical actions.
Passing now over a period of some years, we come to the
G THE PARTICULATE THEORY OF FERMENTATION.
views of Caiguard-Latour, made known in papers presented to
the French Academy dming the years 1835-37.' On examin-
ing fermenting grape-juice, he found (as indeed had been im-
perfectly observed before by Leuwenhoeck and Desmazieres)
that it contained numerous globular bodies which he considered
to be of vegetable nature, and which he found to possess the
power of reproduction, partly by budding and partly, as he sup-
posed, by contracting and liberating numerous spores. From
several facts — amongst others, from finding that in juices not
undergoing alcoholic fermentation these bodies were absent,
while they were always present where that fermentation oc-
curred— he concluded that they were the cause of the fermenta-
tion. He fm-ther found that the de})Osit of which Thenard
spoke, and which he had stated to be the ferment, was composed
entirely of these bodies.
Similar views were announced almost simultaheously by
Schwann,'-* and to him rather than to Caignard-Latour must be
given the credit of having furnished the first real proof of the
view that these cells were the causes of the fermentation.
Schwann prepared infusions of meat, fruits, &c., somewhat
after Appert's method, but, instead of leaving the vessels com-
pletely sealed, he allowed air which had been previously heated
to come in contact with the fluids. The following is his de-
scription of the method which he ultimately adopted.
' Into a three-ounce vessel a small piece of meat was introduced,
and then water was added so that the whole occupied about one-
fourth of the capacity of the vessel ; the bottle was then closely corked,
the cork being firmly fastened down by wire. This cork was traversed
by two small glass tubes, one of which was at once bent downwards
on its exit from the vessel, and its orifice dipped into a small beaker
containing mercury covei-ed by a layer of oil. The other tube ran at
first horizontally and then directly downwards for an inch and a half.
There it had two narrow spiral turnings, then it again ran upwards,
and finally horizontally, being di'awn out to a fine point at its termi-
nation. The cork was covered with several layers of a solution of
caoutchouc in linseed oil, rendered thinner by the addition of oil of
turpentine. The fluid in the flask was now boiled, and the steam was
made to issue from the two tubes till the mercury and oil became so
■ See Annales de CMmie ct de Ph unique, t. Ixviii. 2" seric, 1838.
* Pofjgendorf's Annalen, xli. 1837.
SCHWANN'S EXPERIMENTS.
hot that they no longer condensed the steam. (In order that no
organisms might develop in the water which remained between the
oil and the mercury, a layer of corrosive sublimate was placed between
them.) While the boiling was going on a spirit lamp was placed
under the spirals of the second tube, and the heat was continued until
the tube began to soften (see Fig. 1). Thedropaof water condensing
in the cooler parts of the tubes were dispelled by another lamp. After
boiling bad continued for a quarter of an hour it was stopped, and,
during the cooling of the flask, air passed through the second glass
tube into the vessel, being however j^reviously heated in the spiral
part of that tube. After complete cooling of the flask the orifice of
this tube was sealed and the portion of the tube between the spiral
and the end, containing unheated air, was heated. That being done
the spirit lamp was completely removed.'
Fig. 1. — Schwann's mkthod.
Prepared in this way, the flask contained only boiled meat
infusion and heated air. From time to time this air was
renewed in the following manner : the spiral part of the tube
having been heated almost to melting, the point was broken
and fresh air forced slowly in, the old air bubbling out through
the mercury. After a time the tube was again sealed with the
same precautions as before.
By operating thus Schwann succeeded in preserving meat
and other substances at a temperature of 63° to 77° F. without
any putrefaction, and without the appearance of organisms in
them ; while the same materials when exposed to ordinary air
underwent putrefactive changes in a few days.
8 THE PARTICULATE THEORY OF FERMENTATION.
It was thus evident that there was a something present in
the air, other than the gases of the air which had the power of
bringing about fermentative changes in boiled liquids, and
that this something could be destroyed by heat.
Some -further experiments which Schwann performed with
reference to the alcoholic fermentation furnish additional
evidence against the view that the gases of the air are the causes
of putrefaction.
A solution of cane sugar having been mixed with yeast, four flasks
were quite filled with the mixture and then corked. These flasks
were placed in boihng water for an equal length of time (ten minutes
each). They were then inverted over heated mercury, and air was
introduced so as to displace one-third to one-fourth of the fluid. The
flasks were afterwards corked under mercury and kept at a tempera-
ture of 63° to 77° F. In two flasks the air thus introduced bad been
previously heated, in the other two it had not been so treated. In
four to six weeks the flasks which had received the unheated air
burst, their contents having undergone alcoholic fermentation. The
other two flasks remained unchanged for more than three months.
Schwann states that this latter experiment with heated air
is generally, but not always, successful, and he explains this by
the supposition that after the heating of the mercury, and in
the processes of uncorking and corking, organic matter, which
had not been previously heated, might very possibly mix with
the mercury and enter the flasks. (This view has since been
proved to be correct by Pasteur.)
It is but fair to refer here to the experiments on spontaneous
generation published in 1836 by Franz Schulze. These will
be described at a later period. They are, however, of interest
here, because Schulze anticipated Schwann in the principle of
admitting air previously acted on "in some way or other, in
his case chemically, to Appert's preserves.
Schwann's experiments were repeated and confirmed by Ure
in 1840 1 and by Helmholtz in 1843.^ The latter author, in
order to test the oxygen view still further, prepared an infusion
in the usual manner in a vessel into which platinum electrodes
were fixed. After the infusion had remained unaltered for some
' Journal fiir pralttischc Chemic, xix.
^ Mailer's Archir. 1843.
LIEBICrS VIEWS. 9
time a current of electricity was sent through the liquid,
decomposing the water into hydrogen and oxygen. But even
this oxygen in its nascent, and therefore in its most active state,
was unable to produce any fermentation in the fluid.
In the meantime Liebig had stepped forward as the oppo-
nent of the views advanced by Caignard-Latour and by Schwann.
He proposed a theory of a totally different nature.^ After
pointing out that organic molecules have a tendency to alter
their constitution, to break up and rearrange themselves,
he approacVies the question of putrefaction and fermentation.
With regard to the cause of these changes he writes as follows :
' Cette cause est la faculte que possede un corps en decomposi-
tion ou en combinaison, c'est-a-dire, en action chimique, d'eveiller
la meme action dans un autre corps qui se trouve en contact
avec lui, ou de le rendre apte a subir I'alteration qu'il eprouve
lui-meme.' He compares this sort of action to combustion, and
cites several well-known instances of this kind, such as the de-
composition of nitric acid by an alloy of platinum and silver,
a change which does not take place with the platinum alone ;
or the decomposition of peroxide of manganese by oxide of
silver, &e., in water containing oxygen.
He includes under the term ' eremacausis,' the alterations
which organic substances undergo at ordinary temperatures,
and as the result of the action of oxygen. When oxygen is
excluded, putrefaction occurs. Putrefaction is a combustion
of one or more of the elements of the organic substances at
the expense of their own oxygen. Where no foul smelling
products result, the process is termed fermentation. Putrefac-
tion occurs when the equilibrium of the attractions of a complex
organic molecule is upset, and it results in a rearrangement of
these elements. Non-nitrogenous organic substances do not
imdergo this putrefaction spontaneously when they are pure.
They must be brought in contact with some substance already
undergoing change. This latter substance is therefore termed
a ferment. This ferment is a nitrogenous substance under-
going putrefaction and eremacausis, it converts the oxygen of
the air into carbonic acid, &c. Its activity is destroyed by
desiccation, by heat, alcohol, &c. It is the soluble portion of
' Annalex de Chimir ct de Physitpw, 2« serie, Ixxi. 1831).
10 THE PARTICULATE THEORY OF FERMENTATION,
the ferment which is active, and this does not act by direct
contact, but in consequence of a decomposition which it itself
undergoes. The elements of the ferment take no part in the
formation of the products which sugar furnishes when fer-
mented, though at the same time the ferment is itself under-
going destruction. (This latter statement is based on an ob-
servation by Thenard, who found that 20 parts of fresh yeast,
added to 100 parts of sugar left, after fermentation was com-
plete, only '13*7 parts of an insoluble residue. This residue
placed in a new portion of sugar became reduced to 10 parts.
This last residue no longer exerted any action. Pasteur has
since completely disproved the accru-acy of Thenard's results.
On the contrary he iinds that yeast increases markedly
during fermentation, and in his latest work Liebig admits
this.)
The ferment is, therefore, according to Liebig, a body
undergoing decomposition. If the ferment is too small in
quantity for the sugar, when the decomposition of the former is
complete the latter ceases to ferment (this statement has since
been shown to be quite erroneous), and therefore a sufficient
quantity must be present in order that its decomposition may
not be completed till that of the sugar has ended. No special
substance is, according to this view, required in order to act as
a ferment, but merely one which shall be the constant exciter
of action in the fermentescible substance. (This statement is
also wrong, because putrefying fluids and tissues added to
sugary solutions do not convert the sugar into alcohol. This
was latterly admitted by Liebig, who was compelled to allow
the existence of some relation between the yeast plant and the
alcoholic fermentation, a connection which he, however,
attributed to the effect propagated from the dead and dying,
not from the living, cells.)
Liebig sums up as follows : —
Organic compounds present two opposite and definite
phenomena.
1. They give rise to bodies endowed with new properties,
the elements of several molecules of a more simple compound
uniting to form one molecule of a more com^ilex nature.
2. Some complex molecules of a high degree of complexity
LIEBIG'S VIEWS. 11
break up into one or more less complex molecules of a lower
order, in consequence of the destruction of the equilibrium of
the attractions of their elements. This equilibrium may be
destroyed by heat, by contact with a body of different compo-
sition, or by the action of a body which is itself undergoing
change.
As an example of this Liebig takes the case of urine : ' In
fresh urine,' he says, ' if oxygen be entirely excluded there
occiu-s no alteration of the urea or of the hippuric acid con-
tained in it, but if exposed to the air another substance present
in the urine (probably the mucus) undergoes a change of form
and composition (eremacausis), which is transferred or com-
municated to the urea and the hippuric acid ; the urea is
resolved into carbonic acid and ammonia; the hippuric acid
disappears, and in its place is found benzoic acid,'
He continues : ' When we reflect that the power of exciting
putrefaction belongs to bodies of the most different composition,
that blood, flesh, cheese, saliva, infusion of malt, emulsion of
almonds, &c., acquire this property as soon as, by the chemical
action of oxygen, a disturbance in the equilibrium of the
attraction of their elements has taken place, all doubt as to
the true cause of these phenomena seems to disappear.' (We
shall see later that in this Liebig is wrong, that meat, cheese,
&c., cause putrefaction not from any inherent tendency to do
so or from any state of decay, but because they introduce the
necessary particles into the putrescible liquid.)
Liebig then goes on to say, with reference to the germ
theory of putrefaction, that after the death of fungi and in-
fusoria we observe the same putrefactive phenomena as after
the death of a larger animal. These organisms, according to
him, only appear at a late period of putrefaction, and therefore
are not the cause of it, though no doubt by their vital actions
they must hasten and modify the change.
And now let us pause in the history of this important sub-
ject, aud methodise somewhat the views expressed. These may
be divided into three sets. Firstly, we have that of Gay-
Lussac, who attributes putrefactive and fermentative changes
solely to the influence of oxygen in the flrst instance.
12 THE PARTICULATE THEORY OF FERMENTATION.
Then come the views of Caignard-Latour and Schwann,
refeiTing these changes to the entrance into the fluids of solid
particles from without, which may be destroyed by heat. These
authors go further, and ascribe the whole fermentative process
to the growth of the organisms which are found in the ferment-
ing liquids.
And, lastly, we have the view of Liebig, who looks on oxy-
gen as in so far favouring fermentation that it causes erema-
causis, the molecules undergoing this change being now capable
of setting up putrefactive and other fermentative changes.
The latter changes are therefore due to the presence of some
substance itself undergoing change, and to this substance the
term ' ferment ' is applied. This ferment may be destroyed
by heat.
It will be more convenient if for the present we class these
views under two heads — the oxygen theory (Gay-Lussac's) on
the one hand, and the particulate theory (Schwann's) on the
other. At a later period we shall determine whether Liebig's
or Schwann's is the more tenable view.
I have already mentioned the researches of Schulze, Schwann,
Ure, and Helmholtz as tending more or less to upset the views
of Gay-Lussac.
The next research of importance on this subject is that by
Schroeder and Dusch.' Their aim was to see \N]\eihex jiltraiion
of the air would be sufficient to prevent the fermentation of
boiled fluids. Their apparatus was the following : —
A glass vessel containing the material to be tested (meat infvision,
&c.,) was closed by a close-fitting cork, which was dipped into hot wax
previous to its insertion. This cork had two holes in it wliich gave
exit to two tubes bent outside to a right angle, these tubes being also
firmly embedded in the cork ; one tube was for the purpose of con-
ducting air to the vessel, and the other to suck air out of it.
The conducting tube was connected by means of a short piece of
vulcanised caoutchouc with a glass tube ; the latter was again attached
to a wider tube (1 inch in diameter and 20 inches long) by means of
a similar cork to that in the bottle, and at the other end of this tube
was a cork with a bit of tubing in it, called the open tube. The wide
' Annalen dcr Chcmic tind Pharmacic, 1854.
SCHROEDER AND DUSCH.
13
tube was loosely filled with cotton wool which had been pi-eviously
heated for some time in a water bath.
The other tube — the suction tube — which in the interior of the
flask reached almost to the level of the fluid, was connected by means
of a vulcanised india-rubber tube with the upper tube of an ordinary
gasometer, this latter tube being provi<led with a stop-cock. The
gasometer was filled with water, and on opening the lower tube of
this vessel the water flowed out and thus the gasometer acted as an
aspirator. (See Fig. '1.)
Such was the apparatus employed. The fluid having been
introduced into the flask, and all the connections having been
Fig. 2.— Scheoedee akd Dusch's appaeatus foe supplying
filtered aie.
(Till; tulic to tlic left ought to rcacli almost to the level of the liquid.)
ascertained to be air-tight, the cock of the aspirator was shut
and the substance to be tested was boiled, till all the tubes as
far as the cotton wool had been thoroughly heated ; then, the
joinings having been again examined, the aspirator was so
arranged that water flowed out of it drop by dro}), and thus
sucked air slowly through the flask.
Meat, boiled in water and ke2)t in a flask of this kind with
constant change of air, was preserved for twenty-three days, and
wlicji tested at the end of that time was found to lie quite un-
altered, vvliile a similar infusion left exposed to ordinary air liad
to be removed fioni the laboratory during the second week on
14 THE PARTICULATE THEORY OF FERMENTATION.
account of its intolerable stench. This experiment was repeated
several times with similar results.
Schroeder and Dusch experimented in a similar manner
with fresh sweet malt containing hops. After twenty-three days,
the fluid being still unaltered, the cotton wool was removed, but
the introduction of air — now unfiltered — was continued. The
fluid was muddy and covered with fimgi, and had undergone
fermentation in a week.
These observers were, however, unable to obtain like results
with milk, or with meat heated without the addition of water.
These substances invariably underwent putrefaction.
In a paper published five years later Schroeder returns to
this subject.' Having found that white of egg mixed with
water, if constantly shaken while boiling, could be preserved for
an indefinite time, he tried whether ozone had any power in
inducing fermentation. Dilute sulphuric acid was decomposed
by electricity, and the ozone thus generated was conducted into
a vessel containing pure white of egg. The latter was kept for
thirty-eight days, and was at the end of that time unaltered.
Schroeder was still unable to succeed with milk or yolk of
egg, although the latter, if previously heated in a closed vessel
in an oil bath to 160° C. (310° F.) generally remained un-
changed, and the milk sometimes also kept pm^e.
The special constituents of milk could be easily preserved.
He tested casein prepared by precipitation with acetic acid and
then washing with water. The whey also which remained after
this precipitation could be preserved with ease. When this
whey was boiled a deposit occurred, and this was readily kept
pure ; and the whey which still remained did not ferment
when preserved with the precautions mentioned.
Schroeder tried and succeeded with other materials, such as
blood, urine, starch, &c.
The only substances which failed were milk, yolk of egg,
meat heated without addition of water, and occasionally meat
infusion.
As the result of these contradictory experiments he came
to the conclusion that there were two ways in which fermenta-
tion might be caused ; firstly, by some solid particle which
' Annalcii der Chcmic zoid PJiarviacie, cix. 1859.
SCHROEDER'S VIEWS. 15
can be arrested by cotton wool, and, secondly, by oxygen gas
(in the case of milk, yolk of e^g., &c.).
Two years later there appeared another j)aper by Schroeder
referring to those substances which he had previously failed to
preserve, and in this research he has recoiu-se to the use of
higher temperatures than formerly-'
Yolk of egg, after being heated for half an hour in a closed
glass vessel, at a temperature of 130° C. (266° F.), was placed
in a flask the neck of which was stuffed when hot with cotton
wool, and was again boiled with a little water. This remained
for seventy days unchanged.
He succeeded in a similar manner with meat and milk, and
in the case of the latter he found that prolonged boiling at
100° C. was sufficient.
From these facts he gives up his formerly expressed view as
to the spontaneous fermentation of organic substances under
the influence of oxygen, and concludes that in these fluids
spores were present which could resist a boiling temperature,
the development of these spores being, according to him, the
cause of the fermentation. He further considers that these
spores were present originally in the milk, and were not intro-
duced from the air, because he finds that milk which has not
been Iwiled at all putrefies sooner than pure boiled milk
exposed to the air.
It may be interesting to mention here that similar difficul-
ties were experienced by Appert in his attempts to preserve
milk. He succeeded by the following method : ' Condense the
milk to two-thirds of its volume, strain it, then put it in the
bottle, seal and boil in a water bath for two hours.' In order
to prevent the cream from separating he found it well to add
yolk of Qgg. This did not increase the difficulty in preserving it.
Still fmlher evidence disproving the gaseous theory is fur-
nished by Pasteur.^ He repeated Schwann's exiDeriments and
was successful with most fluids, but for a time he failed in the
case of milk. He, however, succeeded when he boiled the milk
under pressure at 110° C. (2.30° F.) for one or two minutes,
heated air l)eing then allowed to come in contact with it ; and
' Aimalcti dvr Chemie nnd I'karmacie, cxvii. 1801.
- Annalcs dcg Sciences NaUircllcs, scrie iv. t. xvi. 18G1 : Zaolofjic
16 THE PARTICULATE THEORY OF FERMENTATION.
he also succeeded if he subjected the milk to prolonged boiling
at 100° C. Such milk remains unaltered for an indefinite
length of time, but it readily decomposes if unheated dust be
introduced into it in the manner to be afterwards described.
The most striking of Pasteur's experiments is that of the
flask with the bent neck. A flask containing, say, yeast water is
heated so as to render its contents pure. Its neck is drawn out
and bent, and then, after boiling, the lamp is simply with-
FiG. 3. — Pasteur's flask with the bent neck.
(From Pasteur.)
drawn, the neck being neither heated, sealed, nor plugged
(Fig. 3). Nevertheless the fluid does not undergo any change.
If, on the other hand, the neck of this flask be sealed
during ebullition, a more or less perfect vacuum is thus pro-
duced, and then, if the neck be broken after cooling, air rushes
violently into the flask, carrying with it its dust. The result
is that fermentative changes occur in the fluid. In the same
way, if one of the flasks with open necks, the contents of
which have remained for some time pure, has the neck broken
off short, the fluid in its interior rapidly undergoes fermenta-
tion ; or again, if the neck be not bent but be kept straight, so
as to allow dust to fall in, fermentation rapidly occurs.
The explanation of these results is that in the case of the
flask with the long neck the dust is caught in the curve, which
in the first inrush of air is filled with water, which filters the
air (Mr. Lister's view). Pasteur had supposed that part of
the air dust entered the vessel instantly, but that the fluid and
the walls of the flask were at that time so hot that any living
particles present were immediately destroyed.
As will be seen further on. Pastern- also found that it was
TYNDALL. LISTER. 17
not necessary to filter the air of its dust, but that if the air were
merely left undisturbed for some time till the dust settled, it
might then be introduced into flasks without causing any
development.
These experiments have been repeated by various observers
with success, and Mr. Lister has at present in his possession a
flask of this kind containing urine which is now thirteen years
old, but which still remains unaltered and as limpid as on the
day it was prepared.
In a lecture on Haze and Dust,^ Professor Tyndall showed
that if no dust were present in a flask, a beam of condensed
light passed through the vessel in a dark room would only be
visible on each side of it, but would be invisible in its interior ;
in other words, we see light only because there are particles in
the air which render it visible. Were there no particles all
would be darkness.
Such being the case, Tyndall found that when the air
which was admitted to a flask had been previously heated, as
in Schwann's experiment, the beam of light was not visible in
the interior, showing that all or almost all the particles had
been destroyed by heat, or, in other words, were in the main of
an organic nature. By the same method Mr. Lister has found
that in Pasteur's flasks with the long open necks, no floating
dust is present after what was originally there has settled.
Another method of excluding dust was published in 1873
by Mr. Lister.^ It seemed probable that the occasional failures
which occurred in the attempts to preserve boiled fluids arose
from the fact that the steam did not destroy the septic energy of
the dust in the necks of the flasks which had not been previously
heated. Mr. Lister, therefore, in addition to the precautions as to
boiling under cotton-wool caps, &c., subjected his flasks to a high
temperature previous to the introduction of the fluid. This is
done by keeping them, after the cotton cap has been applied,
in an iron box, which is kept at a high temperature for two
hours.
This box is of a square form, with one of its sides movable so as
' Nature, Jan. 27, 1870.
' Microseojncal Journal iox October 1873; see also Tratix. of Path. Society
of London, vol. xxvii. 1878.
C
18 THE PARTICULATE THEORY OF FERMEXTATIOK
to form a door. ' This door has its circumferential part in tbe form of
a groove capable of being packed with a considerable mass of cotton
wool (Fig. 4, f). This door can be secured by means of nuts against the
edge of the box ; and the cotton wool,
having the narrow rim of metal thus
firmly pressed against it, serves as an
effectual filter of the air that passes in
during cooling. But then it is essen-
tial that the heat be so equally distri-
buted as to avoid heating any portion
of the cotton to such a degree as to
destroy its physical properties. This
uniformity of heat is provided foi- by
having three shelves of sheet iron inter-
posed between the large Bunsen's burner and the bottom of the box,
no as to prevent the heat from acting directly upon it, while at the
Fig. 4. — Door of
Lister's box.
Mr.
Fig. 5.— Mr. Lister's hot box.
same time the box is covered over with a cover of sheet iron (Fig. 5, k),
which reaches nearly to the ground, and, while it checks radiation,
compels the heated air to ti-avel over the whole exterior of the box
MR. LISTER'S EXPERIMENTS.
19
and escape by holes at the top of the cover, whence it is conducted
into a chimney by a tube (l). By these two means combined, the
shelves below and the cover round about, we get a uniform browning
of the cotton. Into such a box the requisite number of vessels are
introduced (Fig. 5). An aperture in the top of the box well packed
with cotton wool transmits a thermometer (m), to show us when the
temperature of 300° F. has been reached, and when this, or any other
higher degree short of 350"- F.,
has been continued for two
hours, the gas is turned off
and cooling is allowed to take
place ; and when the apparatus
is quite cool, the covered glasses
may be removed with confi-
dence that they are perfectly
free from living organisms.'
In this manner Mr. Lister
purifies his flasks. The larger
flasks have two necks, a large
vertical one and a lateral one,
which is a bent spout, large at
its commencement and com-
paratively narrow at its shorter
terminal part beyond the bend
(Fig. 6, o). The large size of
the first part prevents it from acting as a siphon, and the result is
that when the liqrdd is poured from such a flask and the vessel is
afterwards restored to the erect position, the end of the nozzle remains
filled with a drop of the liquid, and this guards the orifice so that
regurgitation of air can never take place thiough the nozzle. This
drop of fluid being sucked away by means of a carbolised rag, a pure
cotton cap is tied over the orifice, and the flask is kept for future use.
This flask, purified by heat and with each orifice covered with
pure cotton caps, is used for the experiments (see Fig. 7). The fluid
to be tested is introduced into it by means of a siphon, consisting of
two glass tubes (s and T)connected by a tube of india-rubber (u), with
a stop-cock (v) in the course of the india-rubber tubing. The siphon
is first completely filled with water, the tenqjerature of which should
be higher than that of the air, so that there is no dissolved air given
off to form bubbles. Place one leg of the siphon in the vessel contain-
ing the fluid to be used (w), then turn the tap and permit a sufficient
amount of fluid to flow out to ensure that all the water has escaped
from the siphon ; then turn off the stop-cock, wash the outside of
c 2
Fig. 6.— Mr. Lister's large
double-necked flasks.
20 THE PARTICULATE THEOBY OF FERMENTATION.
the tube (t) with carbolic lotion, wrap a mass of carbolised rag (y)
around its lower extremity, and apply this to the mouth of the flask
(x) as soon as the cottou cap is removed, push the tube steadily
down to the bottom of the flask through the carbolised rag, turn
the stop-cock, and let the required amount of fluid flow into the flask
(Fig. 7). When this has taken place the tap is again turned off", the
Fig. 7. — Method op filling the flasks.
siphon is withdrawn through the antiseptic rag, and a fresh cap of
carbolised cotton (the cotton is carbolised by being soaked in a solu-
tion of one part of crystallised cai-bolic acid in one hundred parts
of anhydrous ether and allowed to dry) is tied over the mouth of
the flask when the rag is withdrawn. The fluid is now heated for
the desired length of time, and then abandoned under the protection
of the caps.
In this way Mr. Lister has found that he can preserve
turnip infusion, hay infusion, urine, fresh milk, &c., for any
length of time without any alteration taking place. To pre-
serve milk, the flask containing it is immersed in boiling water
for half an hour or more.
MR. LISTER'S EXPERIMENTS.
21
Fig. 8.
But this is not all, for these fluids can be transfen-ed to
smaller vessels without undergoing any fermentation after this
transfen-ence. This is done as follows : a liqueur glass (a) is
covered by a glass cap (b) (watch glass), and the whole by a
glass shade (c), the liqueur glass
and the shade standing on a glass
plate (see Fig. 8). This an-ange-
ment is introduced into the hot
box and thoroughly purified.
Thus we have a pm-e glass filled
with pure air, and the problem
is to transfer the fluid from the
flask to the glass without con-
tamination in the process. To
do this, the cotton cap is removed from the nozzle of the flask
(Fig. 7, z) and the end of this is instantly slipped into an
opening in the centre of half an india-rubber ball (Fig. 9, r)
previously steeped in a strong watery solution of carbolic acid.
The outer glass shade is then removed, and the watch glass
being lifted, the india-rubber cap is instantly applied in its
place (see Fig. 9). The required quantity of fluid is then poured
into the glass, and the cap and shade
immediately reapplied. A fresh cotton
cap is now tied over the nozzle of the
flask. In this manner any number of
glasses may be charged, and these are
found to remain as piue and unaltered
as the fluid in the original flask.
And now observe what such experi-
ments teach. In the first place, into
the original flask, when cooling, air
enters, but this air having passed
through a cotton-wool plug is incapable
of causing putrefaction. Then in the
decanting of this liquid from the flask, fresh air must enter
through the large mouth of the flask, but as this passes through
a filter of cotton wool it is in like manner incapable of causing
fermentation. Further the liqueur glasses are full of air, which
lias either been previously heated, or which has been filtered
Fig. 9.
22 THE PARTICULATE THEORY OF FERMENTATION.
through tlie cotton wool around the door of the hot box. The
fluid when poured from the flask into the glass mixes freely
with this air, but no change is set up. And, lastly, the loosely-
fitting glass cap and shade allow a free interchange of air, but
are so placed as to make sure that the air dejDosits its dust
outside the glass, thus corresponding in action to Pasteur's flasks
with the bent necks. In spite of all these opportunities of
admixture with the gases of the air, all sorts of fluids remain
unaltered, while, on the other hand, the same liquids exposed
freely to unfiltered air rapidly undergo fermentative changes.
These experiments are of themselves an absolute proof that
the gases of the air alone are unable to cause fermentative
changes in organic substances.
In 1874 Dr. Eoberts ' demonstrated again that fresh milk
and other substances could be prevented from putrefying if
kept in a flask with a cotton-wool plug after having been pre-
viously boiled.
His method was as follows : An ordinary delivery pipette, having
on it an oblong bulb capable of containing 30-50 cc, was sealed at one
end, and the materials to be experimented on were then introduced
into the bulb until it was two-thirds full (Fig. 10, a). The inside
of the neck of the bulb was next wiped dry, and a plug of cotton
wool was inserted about its middle. Lastly, the neck was drawn
out above the plug and sealed in the flame (Fig. 10, b).
When the bulb Avas thus charged and sealed it was weighted with
a leaden collar, and submerged in tbe upright position (so as to pre-
vent the wetting of the cotton-wool plug) in a can full of water.
The can was placed over a soiirce of heat and boiled for the re-
quired time. The bulb was then withdrawn and, when quite cold,
its neck was filed off above the cotton-wool plug (Fig. 10, c).
Finally it was set aside in the upright position and maintained at a
suitable temperatvire.
By exposure to the heat of boiling water for from twenty to
forty minutes Koberts was able to preserve those substances
with which Schroeder and other observers had foiled, viz., milk,
pieces of meat, and egg albumin.
In 1876 experiments were published by Professor TyndalP
' PMlosojjhieal Ti'ansactiom, 1 874.
" Philomphical Transactiotu, 187C.
DR. ROBERTS' EXPERIMENTS.
23
which afford still fmlher evidence on this subject. I have al-
ready mentioned the method by which he demonstrated the
presence or absence of particles in suspension by passing a
powerful beam of light through the air to be examined. He
found that ' in order to render air optically pure it was only
necessary to leave it to itself for a sufBcient time in a closed
chamber or in a suitably-closed vessel. The floating matter
gradually attaches itself to the top and sides, or sinks to the
bottom, leaving behind it air possessing no scattering power.
Sent through such air the most concentrated beam fails to
render its track visible.'
Fig. 10.— Dn. Roberts' btilbs (copied from Egberts).
His method as described by himself is as follows : ' A chamber or
case was constructed with a glass front, its top, bottom, back and
sides being of wood. At the back is a little door which opens and
closes on hinges, while into the sides are in.serted two panes of glass
facing each other. The walls of this case are smeared with glycerine
in order to make the dust adhere. The top is perforated in the
middle by a hole 2 inches in diameter, closed air-tight by a sheet of
india-rubber. This sheet is pierced in the middle by a pin, and through
the pinhole is passed the shank of a long pipette ending above in a
small funnel. A circular tin collar 2 inches deep surrounds the
pipette, the space between both being packed with cotton wool mois-
24 THE PARTICULATE THEORY OF FERMENTATION.
tenecl with glycerine. Thus the pipette, in moving up and down, is
not only firmly clasped by the india-rubbei', but it also passes through
a stuffing box of sticky cotton wool. The width of the aperture
closed by the india-rubber secures the free lateral play of the lower
end of the pipette. Into two other small apertures in the top of the
cupboard are inserted, air-tight, the open ends of two narrow tubes
intended to connect the interior space with the atmosphere. The
tubes are bent several times up and down so as to intercept and
retain the particles cari'ied by
such feeble currents as changes of
temperature might cause to set in
between the inner and the outer
air (see Fig. 11).
' The bottom of the box is
pierced with holes, in which are
fixed, air-tight, twelve test tubes,
intended to contain the liquid to
be exposed to the action of the
motel ess air.'
The case so prepared is closed
and allowed to stand for three or
four days, till it is found by the
beam of light that all the dust has
settled. Then, the pipette being
dipped into the test tubes, the
fluid to be experimented on is
introduced into each in succession.
They are then boiled for five
minutes in a brine bath. During the cooling, plugs of cotton wool
are introduced into the small external convoluted tubes, but these
plugs are afterwards withdi'awn. The apparatus is then kept at a
suitable temperature and at perfect rest. At the same time a part of
the same infusion boiled for the same length of time is placed outside
the box in free contact with the air.
In this way Tyndall has been able to preserve for an inde-
finite time, boiled urine, mutton infusion, beef infusion, haddock
infusion, turnip infusion, hay infusion, infusion of sole, liver
infusion, infusion of hare, rabbit, pheasant, grouse, codfish,
turbot, herring, mullet, fowl and kidney; while flasks contain-
ing the same infusions, left exposed to the air after boiling for
the same length of time, invariably putrefied in a few days.
Fig. n.— Prof. Tyndall's pure
CHAMBER (COPIED FROM TyNDALL)
TYNDALL. 25
This experiment, though resembling in many respects
Pasteur's experiment with the flasks with long bent necks, differs
from it materially. In Pasteur's ex]3eriment the whole of the
interior of the vessel is acted on by the heat, and thus when the
boiling is ended there is no part of the flask, except the neck,
which contains any particles capable of causing fermentation.
In this case, however, the steam from the tubes, passing into
a larger chamber, is not able to destroy the vitality of the dust
lining the walls of that chamber, and therefore the infusion is
here not only in contact with ordinary air which has not been
acted on by heat nor filtered of its dust, but the septic dust
itself is present in the same vessel though not in actual contact
with the fluids. Tyndall found that as soon as ordinary labora-
tory air, laden with dust, was admitted, putrefaction commenced.
Tyndall has further shown that the gases arising from
ymtrefying substances, however foul smelling, cannot produce
decomposition in other fermentescible liquids, although this
readily occurs when ordinary dust is admitted.
Thus, * on the 30th of November a quantity of animal refuse,
embracing beef, fish, rabbit, have, was placed in two large test tubes,
opening into a protecting chamber containing six tubes. On December
13th, when the refuse was in a state of noisome putrefaction, infusion
of whiting, turnip, beef, and mutton were placed in the other four
tubes ; they were then boiled and abandoned to the action of the foul
sewer gases emitted by their two putrid companions. On December
25th these tubes were still unchanged. On the same day the end of
the pipette was dipped into one of the putrid tubes and then inserted
into the turnip, aiid on the 27th a similar speck was transferred to
the whiting. These rapidly underwent decomposition, while the
remaining two tubes remained unaltered.'
By operating in the manner described by Mr. Lister I have
succeeded equally well in preserving fresh milk, meat, cucumber
or turnip infusion for any length of time. As I shall have to
refer at a later period to experiments in which extensive use is
made of the ease with which these fluids can be preserved
though retaining great readiness to undergo fermentation, I
need not say more at present.
Not only is air which has been filtered incapable of caus-
ing fermentation in a boiled liquid, but air which has been
26 THE FAIiTICULATE THEORY OF FERMENTATION.
acted on by carbolic acid is also without effect. I may
mention a few facts made out by myself in support of this
statement.
In the small room in which most of my experiments were
done it was almost impossible for me to transfer fluids fi"om one
flask to another, by Mr. Lister's method, without contamination
and subsequent fermentation, but if I performed the same
manipulations in a spray of about 1 to 30 carbolic acid and water
I could transfer all sorts of fluids with ease from one flask to
another without any risk, even though done in the most leisurely
manner. In doing this I have used Mr. Lister's double-necked
flasks without the jirotection of the india-rubber cap. I have
also in a few instances simply poured the fluid from one single-
necked flask to another, and when this was done in a carbolic
acid spray without other precaution, the fluid remained pure.
That milk once rendered barren by boiling can be readily preserved
for any lengtli of time, thougli i-etaining its capability for undergoing
fermentation, is shown by the following experiment.
On January 30th milk was prepared by boiling for twenty minutes
in a flask purified by boiling distilled water in it under a cotton cap,
the flnsk being afterwards dried by heat.
On the same afternoon three purified tubes with glass caps and
shades (just like Mr. Lister's liqueur glasses) were half filled with this
milk under the spray.
February 6. — The caps were removed under the spray, and a
heated needle being introduced, jwrtions of the fluid were taken from
each tube for microscopical examination. All the milks were found
to present the normal appearance of fresh milk externally and micro-
scopically.
February 1 1 . — Examined as before. No change.
February 19. — No change.
March 3. — Still fluid and unchanged in appearance. Two of the
tubes were now tested by the addition of a drop of fluid from a tube
containing milk which had been left open, and which had putrefled.
In three days the milk in these two flasks had separated into two
layers, and had lost its normal characters.
April 11.- — The milk in the third test tube still remains un-
changed.
I might multiply instances to show that milk and other
fermentescible fluids can be kept in this way for months at a
MY OWN EXPERIMENTS. 27
suitable temperature, without undergoing any change. This is
not due to any effect of the carbolic acid on the milk, because milk
so preserved rapidly undergoes fermentation when exposed to the
air. Indeed the minute quantity of the solution which comes in
contact with it can have no effect whatever, as is shown by the
following experiment performed in 1877.
February 1. — Five pure tes^t tubes were taken and into each was
introduced 100 minims of boiled milk, along with a certain number of
minims of watery solution of carbolic acid, 1-20.
To No. I. were added 2 mins., making a proportion of 1-1000.
„ II. „ 5 „ „ „ 1-400.
„ III. „ 10 „ „ „ 1-200.
„ IV. „ 20 „ „ „ 1-120.
„ V. „ .50 „ „ „ 1-60.
They were then shaken up and left exposed to the air for twenty-
four hours, and afterwards covered with very loosely- fitting caps,
which were removed at intervals during the following day.
February 6. — The milks wei'e beginning to alter in appearance
and to separate into layers. This was the case even in No. V.
April 19. — They were all much advanced in decomposition.
Thus we see that decanting can be safely done in a spray
of carbolic acid, the fluid still remaining as putrescible as ever ;
while, on the other hand, experience had taught me- that in the
particular room to which I have referred, it was very difficult
to decant successfully without the spray.
The following experiment which I performed some time
ago directly proves the efficacy of the spray : —
Two flasks containing pure milk were opened in my room, and
left open for ten minutes. In both bacteria developed. As soon as
these flasks were removed two other flasks similarly charged were put
in the same place in a fine cloud of carbolic spray. They were opened
and left open for ten minutes. Both of these remained pure, though
when inoculated at a later period organisms rapidly developed in them.
When they were removed the spray was stojiped, and two fresh flasks
were placed in the same position, opened and left open for ten minutes.
One of the latter lemained pure ; in the other organisms appeared.
(As will be later seen, the presence of organisms is synonymous with
the presence of fermentation, and their absence with the absence of
such changes.)
28 THE PARTICULATE THEORY OF FERMENTATION.
Another experiment proves to demonstration the efficacy of
the spray in destroying the putrefactive agents in the air : —
Four flasks provided with cotton caps were puiified according to
Mr. Lister's method. Into two of these, pure encumber infusion was
introduced in the manner ah-eady described. These two flasks were
placed for four days in an incubator, kept at the temperature of 98° F.
At the end of this time the fluid was unchanged in both. About
half of the liquid in one of the flasks was then poured into one of the
empty previously purified flasks, in a cloud of carbolic spray, and the
caps reapplied. These were then placed in the incubator and they
remained permanently unchanged, and without the development of
organisms. The same process was gone through with the two flasks
without the use of a spi^ay. In both of these organisms developed
and putrefactive changes occurred.
In this experiment, when the fluid was poured from one
vessel to the other it passed through the air, and air also
entered into the first flask to take the place of the liquid.
When this air had not been acted on by carbolic acid, organisms
developed and fermentation took place, but where the air had
previously passed through the spray it failed to cause any
further change. (1 do not of course mean to imply that the
former will be a constant result, for in ordinary air there are but
few organisms present, and probably many flasks would escape.
This experiment refers to the air of the room in which it was
performed, that air being loaded with causes of fermentation.)
A very striking proof of the value of the carbolic acid
spray which occm'red to me lately may be mentioned. The
flasks which I at that time used were purified by heating them
to a temperature of about 600° V. in a box like that described
by Mr. Lister. The flasks were in the first instance heated
without any covering, the cotton caps were then applied under
the spray, and the flask with its cap reintroduced into the box,
where it was thoroughly dried in order to drive off any carbolic
acid which might be adhering to it. As the temperature to
which the apparatus was in the first instance raised chars cotton
wool, I used asbestos to filter the air as it passed into the
interior of the box during cooling. For a while this answered
quite well, but after a time portions of the asbestos became
detached, and holes were thus formed through Avhich air could
(JONCL USIONS. 29
enter without being filtered, and as a result on several occasions
I found that all the flasks so prepared were impure. This
was obviated simply by directing the spray against the door of
the box as soon as the lamp which heats it was extinguished.
The box was thus surrounded by spray; the air passing into
it first passed through this spray, and, as a result, since I
did this, I never failed in any instance in obtaining pure flasks.^
From these researches we learn that the gases of the air,
whether oxygen, nascent oxygen, ozone, nitrogen, carbonic acid,
emanations from fermenting substances, &c., are powerless to
cause fermentation in boiled fluids or tissues. Further, that
it is sufficient, in order to prevent this occurrence, that the air
be either previously heated, or filtered through cotton wool, or
acted on by chemical substances, such as sulphuric acid or
carbolic acid, or merely allowed to remain at rest so as to
permit the dust to settle outside the substance tested. It is
therefore evident that the causes of putrefaction in boiled
substances are solid particles present in the atmosphere and on
surrounding objects, which may be deprived of their fermentative
properties in various ways. When we come to consider the
further questions of spontaneous generation and the relation of
organisms to fermentative changes, we shall find much additional
evidence confirming this view.
' The exact merits of the carbolic spray as a means of purifying the atmo-
sphere will be discussed later. What I wish to point out here is, that in
ordinary air, in circumstances where we know that particles capable of causing
fermentation are present, carbolic acid is able to render these particles inert.
30 THE PARTICULATE THEORY OF FERMENTATION.
CHAPTER II.
THE PARTICULATE THEORY OF FERMENTATION (continvrd). —
ON THE FERMENTATION OF UNBOILED SUBSTANCES.
Grape juice — Gaji-Lnssac — Van der Broech — Pasteii/i' — liohcrts; blood — Van
der Brocch — Pasteur — Burdoii-Sanderson — Lister — 3Iy awn results ; un-
boiled ui-ine — Vaih der Broecli, — Pasteur — Lister — My own results — Roberts
— Cazeneure and Livon ; milk — Hojfpe-Seyler — RoleHs — Lister — My own
experiments; egg albumen — Van der Broecli — Gay on — Roierts — 3Ty own
exjJenments ; vegetable tissues — Roberts ; animal tissues — Billroth — Tiegel
— Bur don- Sanderson — My own experiments — Chiene and Ewart — Meissner —
General review of the facts — Behaviour of similar fluids and tissues in the
living body — Principles of aseptic surgery.
While it cannot be doubted that the causes of the fermenta-
tion of boiled fluids and tissues are particles which reach them
from the air and from surrounding objects, is this equally the
case with the unboiled ? Experiments with these substances
are apt to yield very contradictory results, for it is a matter of
extreme difficulty to prevent their contamination after their
removal from the living body. How this has been managed
and with what results we must now enquire.
I. — Orape Juice.
Gay-Lussac in the research mentioned before attempted to
ascertain whether unboiled grape juice remained unaltered when
oxygen gas was excluded. He took a bell jar and introduced into
it small grapes, still intact. The jar was now reversed over
mercury, and was filled five times with hydrogen gas in order
to wash out all the oxygen. The grapes were then crushed by
means of an instrument introduced through the mercury, and
the juice thus obtained was kept at a temperature of 15° to 20°
C. Fifteen days later, no fermentation having taken place, a
THE FERMENTATION OF UNBOILED SUBSTANCES. 31
small quantity of oxygen was introduced, and immediately
fermentation commenced.
From these experiments he concludes that the oxygen
introduced caused the fermentation. But here there are two
main fallacies. In the first place, the skins of the grape were
left mixed with the grape juice, no sufficient means being
taken to destroy any solid particles adhering to them ; and then
also the oxygen introduced might have carried in the necessary
particles. There can indeed be no doubt, from Pasteur's sub-
sequent investigations, that the Torula cerevisise — the cause of
the alcoholic fermentation — was present on the skins of the
grapes ; and Pasteur has further shown that oxygen is absolutely
necessary for the development of the old cells of the Torula,
though the young cells may go on developing without the
presence of free oxygen. The explanation of Gay-Lussac's
experiment is, therefore, that the old Torula cells present could
not develop without oxygen, but that when a small quantity
of oxygen was introduced, they developed, and fermentation
occurred.
The next attempt to preserve grape juice of which I can
find any record was made by Van der Broeck, and narrated to
the ' Provincial Gresellschaft fiir Kunst und Wissenschaft,'
Utrecht, January 1858. His method was the following' : —
Small beakers were filled with mercury, and then heated in a sand
bath till the boiling point of the mercury was almost reached. Fi-om
time to time they were placed under the receiver of an air-pump, and
at the same time shaken in order to detach any bubbles of gas adher-
ing to the side of the flask. This process of heating and exhausting
was continued till all the air was removed from the bottom or sides
of the glass. These glasses were then inverted in a basin containing
previously heated mercury, and were firmly fixed in this position.
Ripe and uninjured gi'apes were now passed into the mercury and
brought under the orifice of the flask, a portion of the skin of the
gi-ape was clipped out by a heated knife, and by gentle pressure some
of the juice was made to ascend m the vessel, the rest of the gi-ape
being removed. When a sufiicient quantity of juice had been thus
introduced the vessels were placed in a room of which the tempei'a-
ture was 2.5° to 28° C, and giupe juice thus obtained could l)e kept for
months or years without undergoing any change.
' See Annalcn der Chcinie unci Pharniacir, cxv. 18G0.
32 THE PARTICULATE THEORY OF FERMENTATION.
In this experiment not only was all air excluded, but the
dust adhering to the walls of the vessel and in the mercury
was subjected to strong heat, and its fermentative power
destroyed. The juice of the grape, in ascending through
the mercury, did not come in contact with unheated dust, nor
did it touch the skin of the grape.
Into some of the flasks containing pure grape juice obtained
in this way, pure and fresh oxygen was introduced from a retort
containing chlorate of potash and oxide of copper. (The
nozzle of the flask was heated previously to its immersion in
the mercury, and the oxygen was allowed to stream out for a
time sufficient to wash out all the dust.) In none of these
flasks was there a trace of fermentation. Into others, atmo-
spheric air, passed through a mass of cotton wool, was intro-
duced in the same manner, but without producing any effect.
Into these vessels containing oxygen, yeast was introduced
in minute quantity, and fermentation at once commenced.
Into others containing only grape juice, young cells which had
never been exposed to free oxygen were introduced by a
method which is fully described in his research, and these also
caused fermentation ; thus proving that oxygen is not necessary
even for the commencement of the change, if only the yeast
cells be young (three or four days old).
By these experiments it was absolutely demonstrated — 1
That oxygen is not the cause of the fermentation of unboiled
gra})e juice ; and 2. That the juice itself contains no ferment.
That grape juice contains no ferment was further shown
by Pasteur,' who introduced unboiled juice into his flasks with
bent necks, containing pure boiled juice. No fermentation
occurred, though, as he says, if a single Torula cell had been
added, the whole mass would have fermented.
Dr. Roberts - likewise succeeded with grape juice.
Test tubes were drawn out at their lower ends to capillary
points and sealed in the flame; the upper ends were plugged with
cotton wool ; they were then passed and repassed through the flame of
a spirit lamp until they were quite hot, as shown by the commencing
charring of the cotton. (Fig. 12.)
' Eleven sterilised tubes, six empty and Ave containing water, were
' Etudes sur la BVcre. ^ PhM. Transactions, 1874:.
PRESERVATION OF GRAPE JUICE AND BLOOI). 33
grape
urface
charged with grape juice in the following manner : — A fresh
was firmly seized with the fiiiger and thumb, and a spot on its s
was pi-essed for a few seconds against the flame
of a spirit lamp so as to destroy any adhering
germs. The point of the sterilised tube, also
heated in the flame and quickly snipped off" by an
assistant, was then thrust into the grape at the
heated spot. Compression was now made on the
gi-ape until a sufiicient quantity of the turbid
juice was forced into the tube. The tube was
then withdi-awn, and its point sealed in the
flame. The eleven tubes thus charged remained
permanently unchanged, and when examined, at
various periods from five to eight weeks, the taste
and reaction of their contents were undistin-
guishable from that of the fresh grape juice.'
II.— Blood.
Blood is one of the substances which eobeets).
have been frequently referred to as having
an inherent tendency to decompose, but several experiments
have now demonstrated that this is not the case.
The first observer who succeeded in preserving blood was
Van der Broeck.
Van der Broeck procteded as follows: — Having prepared his
beakers filled with mercury as formerly described, he introduced one
end of a previously heated copper tube into the carotid artery of a dog.
To the other end of this a caoutchouc tvibe was connected, while the
free end of the lattei- dipped into the mercury and the blood passed
along it into the purified beakers. (This caoutchouc tube had been
purified by the jjassage of steam through it for some time, and by
placing a plug of cotton wool in each end while it was cooling.)
The vessels were then kept at a temperature of 25° to 30'^ C. for
weeks without the contained blood undergoing any change.
Into some of these flasks oxygen or filtered air was intro-
duced, but still there was no putrefaction. The minutest por-
tion of putrescent or even non-put re scent but unheated substance
at once set up fermentation.
In 1863, Pasteur ' stated that he had obtained blood from
' Comptcs llcnduv, Ivi. 738.
])
34 THE PARTICULATE THEORY OF FERMENTATION.
healthy iinimals by means preventing contamination with un-
heated atmospheric dust, and that this blood had remained free
from change. In a later publication ^ he describes the method
pursued.
' For this I made use of a flask connected by means of a
caoutchouc tube with a brass tube and stop-cock. The two parts
of the tube are about twelve centimetres in leugth ; that which is
free is filed down like the extremity of a cauula. In order to cleanse
this vessel from all living dust the free extremity of the brass tube
was connected 'with a platinum tube .strongly heated, a small
Fig. 13 (FROM Pasteur).
quantity of water having been previously introduced into the flask.
This water is then boiled, and the flask allowed to cool, the air which
enters during cooling being previously heated. It is well to boil the
water in the flask under pressure, to effect which the free extremity
of the platinum tube is connected with a glass tube bent at right
angles, which dips into a deep vessel filled with mercury. After
boiling for some time under pressure, this tube is detached, and boiling
is continued at the ordinary pi-essure ; then the flask is allowed to
cool and to become filled with heated air. When the flask is cold the
cock is shut and the platinum tube detached. Till it is required it is
well to hold the orifice of the brass tube down, in order to prevent
dust from falling into it. Before being used this portion is heated
carefully in the flame of a spiiit lamp.
' A vein or artery of a dog is now opened, the end of the brass tube
introduced, and secured in the blood-vessel by a ligature ; the cock is
then turned on. Blood flows into the flask, and when enough has been
ol>tained the cock is shut and the flask placed in a suitaljle tempei'a--
ture.'
As a result this blood does not putrefy, and its odour re-
mains quite fresh. There is not even an active absorption of
' Etudes xvr la JJihr, 187G.
BLOOD: BURDON-S ANDERSON, ROBERTS, LISTER. 36
oxygen, for after several weeks only 2 or 3 per cent, of that
gas was found to have disappeared in a vessel sealed imme-
diately after the blood had been introduced.
Dr. Burdon-Sanderson • also found that blood taken from
rabbits with suitable precautions, and put into purified flasks
covered with cotton wool, remained free from change.
Dr. Eoberts,^ having purified his tubes in the way described,
and having thoroughly cleansed his finger, punctured it, and
sucked up about two drops into each tube. Of ten tubes pre-
pared in this way, six remained unaltered. This experiment
is of little value, partly on account of the imperfect method of
experimentation, and partly on account of the small amount of
blood obtained.
Mr. Lister ^ took blood from the jugular vein of an ox in
the following manner : —
A large glass tube was fixed in the lai'ge oiifice of one of his
double-necked flasks, the interval between the flask and the tube
being filled with tightly-packed cottou wool. Over the outer end of
this glass tube a cotton cap was applied, and there was a cotton cap as
usual over the orifice of the spout. The fiask thus arranged was heated
in the hot box. The jugidar vein of an ox having been exposed
antiseptically, was divided, the cotton cap removed fi'om the end of the
tube, and the end of the vein slipped over the orifice of the tube.
Blood thus flowed through a pure tube into a pure flask. When
enough had been obtained the vein was removed and a pure cotton cap
immediately aj^plied in its stead. Before coagulation had occurred,
various liqueur glasses, arranged as formerly described, wei'e charged
from the large flask.
Blood so obtained remained unaltered in the liqueur glasses
and in the flask, though kejit for six weeks.
Mr. Lister also found that not only blood, but blood and
water — a much more putrescible mixture — remained unaltered.
(The water was introduced into a large pure flask, and boiled so
as to purify it. A portion of blood clot from one of the liqueur
glasses was then spooned into the flask, careful precautions
being taken against the entrance of living dust.)
In some experiments, performed in a manner to be shortly
' Quarterly Journal of Micraisropiful Sriciicr, xi. J871.
- Loc. cit, '■' Mirriixropical Jour mil, 1878.
1) 2
36 THE I'ARTICULATE THEORY OF FERMENTATION.
described, I have found that blood, removed from the healthy
living body and placed in calcined flasks or in flasks containing
infusion of cucumber, maybe preserved for an indefinite length
of time without alteration.
Hence blood has no inherent tendency to undergo fermen-
tative changes, nor can oxygen alone induce such alterations.
III. — Urine.
Healthy mine was first preserved without alteration by Van
der Broeck. The flasks in which it was received were prepared
in the manner before described. An animal (dog or sheep)
was killed, the abdomen was immediately cut open, and the
ureters and m-ethra having been rapidly tied, the bladder was
removed and immersed in the mercury. A heated needle was
then introduced, and the bladder was torn, the urine then
ascending into the glass. This urine remained pure even after
the addition of oxygen or filtered air.
In the same paper in which Pastern- mentions that he has
succeeded in preserving blood he states that he has also
obtained pure urine. The method is described in his ' Etudes
sui* la Biere.' The flask with its nozzle and stop-cock are
prepared as in the case of the blood ; then the free extremity of
the brass tube is introduced into the urethra. Urine being
passed, the stop-cock is turned, and the urine flows into the
flask. Urine thus obtained undergoes no fermentation. ' Elle
depose des cristaux en petite quantite, mais sans se troubler
ni se putrefier d'aucune facon.'
In 1871 Mr. Lister succeeded in obtaining and preserving
unboiled urine.' The method he employs is to wash the
meatus urinarius and the glans penis with 1-40 carbolic lotion.
A prepared flask is then taken, the cotton cap is removed, the
glans immediately applied over the orifice, and urine passed
into the flask. A fresh cotton cap is then applied. This
urine may, like other fluids, be decanted into liqueur glasses.
This experiment was apparently constantly successful, no alter-
ation occurring in the urine in the flasks or in the glasses.
' Transactions nj the Itvijal Society of Edinhuryh, 1875.
URINE: ROBERTS, CAZENEUVE AM> LI FOX. 37
I may here state that I have often repeated this experiment
with the view of obtaining pm-e nnboiled urine for other experi-
ments, and always with success. I have, however, used the spray,
and have thus avoided the necessity of applying the glans penis
to the orifice of the flask. The glans having been purified,
urine is simply passed in a spray of carbolic acid into a pure
flask. This urine passed through the air, but that air, having
been acted on by carbolic acid, was inert.
Dr. Roberts has also obtained similar results by passing urine
into a pure test-tube, and afterwards charging tubes of the
form previously described, by breaking oft the capillary end
below, and letting the urine flow up. Of eight tubes so
obtained, the urine remained unaltered in seven, while in one
it putrefied.
Cazeneuve and Livon ^ succeeded in preserving urine in the
urinary bladder without the occurrence of any alteration in it.
A ligature was placed around the prepuce of a dog for five
hours, in order to have a considerable amount of urine in the
bladder. An incision being made into the abdominal cavity at
the end of that time, the ureters and the urethra were ligatured,
and the bladder was cut out. The bladder was then suspended
in the air at a temperatm-e of about 25° C. The wall of the
bladder soon dries, and though liquid slowly transudes, that
liquid evaporates immediately, and thus the bladder wall cannot
putrefy. Urine may be kept thus for several days without
undergoing any change, although if the bladder be opened it
becomes ammoniacal in twenty-four hours. I shall return to
these experiments at a later period.
Thus healthy unboiled urine has no inherent tendency to
putrefy, but follows the same law in this respect as boiled
urine.
IV.— Milk.
In 1859 Hoppe-Seyler attempted to preserve milk pure in
the following manner: — ^
A small funnel was carefully fastened over the teat of a goat. To
the lower end cf this was fastened a piece of caoutchouc tubing, the
' Rcrue Menmclle, 1877, p. 733.
^ Vircliow's Archiv. xvii. (1859).
38 THE PARTICULATE THEORY OF FERMENTATION.
other end of which was attached to a glass tube below. This glass tube
passed down to the bottom of a glass test tube, the u])per vim of
which was provided with a piece of caoutchouc tubing open above.
None of the tubes were heated nor in any way purified. The milk
was now withdrawn in a continuous stream, so as to flow for a long
time over the edge of the caoutchouc tube till it was quite free from
bubbles of air. The test tiibe was then lowered, and then, while the
milk was still flowing, the caoutchouc tube was firmly tied around a
thick glass rod.
Milk obtained in this manner, and kept at the ordinary
temperature, coagvdated in three days. Hoppe-Seyler therefore
concluded that milk when shed contains a ferment.
This experiment proves that oxygen is not necessary for the
occurrence of fermentation in milk ; in other words, it is not the
cause of such changes, and therefore, as the tubes were not
purified, the cause must either be in the milk itself or be some-
thing adhering to the tubes. As I have just stated, Hoppe-
Seyler concluded that the cause was inherent in the milk.
Which of these is the true agent is decided by the following
experiments performed by Dr. Eoberts : — ^
* A glass tube was drawn out at each end to a narrow orifice. The
lesser portion of this was tightly wrapped round with cotton wool and
inserted as a plug into a large test tube containing water to the depth
of one inch. A cap of cotton wool was also tied over the narrow
orifice. The water in the test tube was then briskly boiled, and the
boiling was continued almost to diyness. When the apparatus was
cold I took it into the cowhouse, and seizing a teat, I pulled ofi"
qvuckly the cotton- wool cap and pushed the narrow point into the
duct of the teat. Holding it firmly in this position I milked into the
test tube until sufiicient milk had been obtained. I then drew away
the test tube from the little tulie, pressing in the cotton wool around
it as I did so, until the latter was entirely withdrawn from the test
tube.
' From the test tube I charged ten empty pure tubes ' (in the manner
descril)ed under urine), 'and resealed their capillary orifices : of these
ten tubes three remained unchanged, the milk remaining perfectly
normal as regards taste, reaction, kc. The other tubes curdled or
putrefied in ten days.'
' Loc. cit.
MILK: LISTER, MY OWN EXPERIMENTS. 39
The method described here is imperfect, but the fact that
three tubes remained unaltered absolutely demonstrates that
the cause of the fermentation is nothing inherent in the milk
itself, but something which it acquires after it leaves the body —
that something being particulate, not gaseous.
Mr. Lister ' describes several series of experiments performed
with the same aim. In one of these he succeeded in preserving
the milk unaltered.
A numbei' of little tubes were covered with glass caps and shades,
and purified in the usual manner. After a rainy day he washed the
udder of a cow and the hands of the milkman with water. A
wide glass tube connected with an elastic tube was then placed under
the nipple (the glass tube had been heated and the elastic tube
boiled). This -was filled with milk, and then each little tube in suc-
cession had a small quantity mtroduced by relaxing the elastic tube.
Of twenty-four tubes so prepared and charged two remained
permanently pure. The results in the other tubes equally demon-
strated that the cause of the fermentation of milk is not inherent
in the milk, for the milk in each underwent a different change.
These experiments will be more fully considered at a later
period.
While in the Shetland Islands in the summer of 1880 I
performed a series of experiments, which consisted in obtaining
the milk under the protection of a spray of carbolic acid. A
number of flasks with cotton caps and long necks were heated
before leaving London. The udder of the cow and the hands
of the milkmaid being washed with carbolic lotion (1-20), the
flasks were uncorked and filled with milk under the spray.
In doing so the mouth of the flask was held as close as possible
to the teat. The cow was restive and would not allow me to do
the milking, and therefore the experiment was performed by
the milkmaid. When the restiveness of the cow, the inex-
perience of the milkmaid at antiseptic work, and the dark and
draughty cowhouse are taken into account, it will not be sur-
l)rising that the milk in a considerable number of the flasks
f(;rmented; but nevertheless evidence was got, of tlio same
kind as that obtained by Dr. Roberts and Mr. Lister, sufficient
' Micrusccjncal Jourmil, 1878.
40 THE PARriCULATE THEORY OF FERMENTATION.
to disprove the existence of a ferment in the milk when with-
drawn from the body.
In order to transfer these flasks to London I had intended
to draw ont and seal their necks, but I found this impossible,
and therefore I soaked pieces of cork in carbolic lotion, inserted
them into the mouth of the flask, and covered them with tar
— a very inefficient method. During the voyage the milk was
much shaken, and some of the corks proved inefficient, as shown
by the leakage of the milk.
The following are the experiments, with their results : —
First Experiment.
August 5, 1880. — The udder and teats of the cow and the hands
of the milkmaid having been Avashed with 1-20 carbolic lotion, and a
small spray being directed as well as possible over the part, eight
purified long-necked flasks were filled with milk, the milk being
drawn directly into each flask, which were held as near the teats as
possible. Eash flask was re-covered with its cotton cap, and they
were then placed in the upright position in a warm room.
Augtist 8. — The milk in these flasks seems unaltered. There is a
little cream on the top in each.
August 10. — Ditto.
August 24. — Four of the flasks have undergone change, the change
varying in nature in each flask. The other four are perfectly fluid
and present the appearance of pure milk.
To-day the corks were inserted.
Se2:)temher 21 (twenty-three days after the transport to London). —
Only two flasks now remain pure, the other six having undergone
alterations of various kinds.
October 27. — Examined. The milk in two flasks is perfectly
normal.
The result of the first experiment was, that after nineteen
days four of the milks had undergone alterations of various kinds,
while four remained apparently pure. On October 27 — i.e.
after two months and twenty-two days — two milks were still
perfectly right, in spite of a sea voyage and great disturbance.
MILK: MY OWN EXPERIMENTS. 41
Second Experiment.
(«) August 10. — Two flask?^ were filled after washing the udder of
the cow and the milkmaid's hands with carbolic acid (1-20). No
spray used.
August 24. — The milk in one of these flasks has undergone altera-
tions \ the milk in the other Ls perfectly pure.
September 21. — Both milks have coagulated and are undergoing
changes.
(b) August 10. — After the spray employed in experiment (c) had
been stopped, two flasks were filled without it.
Augiist 24. — I am doubtful whether these are pure or not ; I think
they are not.
September 21. — Changes have occurred in both.
(c) August 10. — Seven flasks were filled under the spray as usual.
August 24. — Three of these milks have altered ; four are still
apparently pure.
September 21. — Three still remain apparently pure : four have
undergone change.
October 27. — Examined. Three still pure.
On December 24 I opened one of these flasks, and found a slightly
suety smell but a perfectly sweet taste, and the milk presented the
appearance of normal milk. I examined it microscopically — no
organisms. I have stained some specimens of this milk (Plate V.
Fig. 33), and it will be seen that no organisms whatever are present,
and this in unboiled milk kept for moi'e than five months.
The result here is that three out of seven of the flasks filled
under the sjjray have remained permanently pure, while all of
those filled without the spray have ultimately undergone
fermentative changes.
Third Experiment.
(a) August 1 6. — One flask filled without spray and without previous
application of carbolic acid to the hands or teats.
Aiigust 24. — This milk has coagulated.
{b) Aiigust 16. — One flask filled without the spraj' and without
washing the teats with carbolic acid. The hands of the milkmaid,
were, however, purified.
August 24. — This milk has undergone fermentation, having
separated into two layere — the upper clear, the lower thick but not
coagulated.
42 THE PARTICULATE THEORY OF FERMENTATION.
(c) August 16. — Two flasks were filled without the spray, but after
washing both the teats and the hands with carbolic lotion.
AiKjust 24. — One of these is doubtful, the other apparently iin-
altered.
Septeiniber 21. — Fermentative changes are occurring in both.
{d) August 16. — Six flasks filled under the spray as usual.
Aug^ist 24. — All these are appai-ently unchanged.
September 21. — Four have undergone some fermentative changes.
One is doubtful. One is still pure. Thi-ee of the corks have not
fitted perfectly.
October 27. — Examined. One still pure.
The whole result is, that of twenty-one flasks filled under
the spray, six remained permanently unaltered, and that after
having been exposed in a manner which sufficiently explained
the occurrence of femientation in some of the others.
Up till August 24th no less than fourteen of these milks had
remained apparently unchanged, while similar specimens taken
without any precautions had undergone alteration,
I have still in my possession (June 1881) four of these
six flasks, and the milk in these still remains perfectly pure
and free from fermentative changes.
From all the facts narrated I think it is absolutely certain
that milk has no inherent tendency to undergo fermentation
of any kind, and that the cause of the fermentation is not
the gases of the air, but solid particles which the milk meets
with after it is drawn from the cow.
V. — Egg Albttmen.
The difficulty experienced by Schroeder in preserving boiled
white and yolk of eggs will be remembered.
Van der Broeck introduced an egg into the merciuy ar-
ranged as formerly described, broke the shell with a heated
iron rod, stirred up the contents with a similar rod, and then
allowed them to ascend into the glass. This egg albumen
remained pure, even after subsequent addition of oxygen or
of filtered air.
Gay on ' found that some eggs may be preserved unaltered,
while others undergo change. He supposes that in the latter
' C'onijjtvg Itendiix, Ixxvi. Ixxvii.
EGG ALBUMEN: ROBERTS. 43
case the causes of putrefaction entered as the egg passed through
the oviduct. Such an idea is, however, hardly tenable.
Eoberts has shown by experiments similar to those pre-
viously described that egg albumen has no inherent tendency
to undergo fermentation.
He proceeded in the following manner : — Eight sterilised tubes
were prepared containing pure water. ' A fresh egg was fixed in a
convenient support, and a small piece of the shell was chipped off,
care being taken to leave the subjacent membrane uninjured ; then a
sterilised bulb was taken, and the capillary portion immersed for a
few seconds in boiling water, in order to destroy any adherent septic
particles. The sealed end was then rapidly snipped off and the
capillaiy portion plunged into the interior of the egg. About 2 gm. of
the albumen were then sucked up by the mouth into the bulb. When
this was accomplished the bulb was quickly withdrawn and its capil-
lary end sealed in the flame.'
Six of these eight tubes remained unaltered for seven months.
Of a second series of seven tubes similarly charged and kept for
two months, five remained unaltered. That is, of fifteen tubes filled,
eleven remained pure.
I may refer to an experiment which I did for another
purpose, accepting as true the view that egg albumen had no
inherent tendency to undergo fermentation, aud which proves
the truth of that view.
On July 7th, 1880, 1 took four purified beakers and four fresh eggs.
These eggs were washed with carbolic lotion (1-20), and were then
Ijroken, one into each lieaker, under the spray.
One of these beakers was covered with its cotton cap, and placed in
an incubator kept at the temperature of 98° F.
On July 20th no change whatever had occurred. The other flasks
were used at once for various experiments. Into one a special form
of organism was introduced, and here only this one form of organism
developed, with the production only of a special kind of fermentation.
Hence egg albumen has no inherent tendency to undergo
fermentative changes.
44 THE PAliriCULATE THEORY OF FERMENTATION.
VI. — Vegetable Tissues.
Dr. Eobei'ts' has also experimented on the solid tissues of
the turnip, potato, orange, and tomato, with similar success.
The following is his method for turnip : —
' A stei-ilised tube containing- water was nickecl with a file near the
base of the capillary part, where the tube had a diameter of about two
millimetres, A fresh oblong turnip was then fractui-ed aci-oss, and
the tube, snipped off at the nicked jjoint, was quickly thrust into the
substance of the turnip. A naiTow cylind-er of turnip about an inch
long w'as thus foi-ced into the column of water in the tube. The tube
was then detached, and its end sealed with melted sealing-wax.' Of
14 tubes thus chai-ged with turnip 10 were successful;
7 „ „ potatoes 4 „
8 „ „ orange 8 „
3 ,, ,, tomato 3 ,,
Ferments which induce changes after death are therefore
not present in living vegetable tissues.
VII. — Animal Tissues.
Some years ago experiments were made by Billroth ' and
Tiegel^with the view of ascertaining whether the living tissues
did or did not contain the causes of putrefaction. Having
killed an animal, they opened its body rapidly, and removed with
heated implements various portions of tissue such as liver,
spleen, kidney, &c., and immediately dropped this into heated
paraffin. They supposed that by this means any dust which
fell on the tissue in its transit from the body to the flask would
be destroyed by the hot paraffin, while this heat would not
penetrate into and act on the interior of the tissue. At the
same time the organs would be protected from air or dust by the
paraffin.
They found that many portions of the body preserved in
this way, notably the liver and spleen, underwent putrefaction
rapidly, and they therefore concluded that the causes of this
putrefaction were present in the living blood and tissues.
' CuceohacteHa sejHica. * Virchow's ArcJiir. Ix.
ANIMAL TISSUES: MY OWN EXPERIMENTS, 45
These experiments were repeated by Dr. Burdon-Sauderson,
who obtained similar results and adopted the same views.
If, however, we look at the method, we shall find several
objections to it. Thus, heated paraffin must be looked on as
dry heat ; it does not moisten solid particles in contact with it.
Now it has been shown that dust, if kept dry, may be heated
even to 300° F. without losing its power of causing fermenta-
tion. Further, paraffin solidifies at about 136° F., or even
lower, and therefore paraffin, merely at its melting point, is not
likely to be hot enough to destroy all septic particles. Further,
during the cooling of the paraffin heavy particles of dust may
fall into it and sink on to the tissue. Then, also, on the sides
and bottom of the vessel is coarser dust, which likewise may not
be destroyed.
But, again, paraffin is very apt to crack, and after cooling
small cracks may occur which admit moistm-e and dust. To
obviate this risk the paraffin has been covered with oil ; but even
here the oil becomes laden with dust and passes down through
the cracks.
And, lastly, the knife, before dividing the tissue, compresses
the vessels and forces the blood out of them, and thus, when
these vessels are cut, air is sucked in, and this air carries its
dust with it quite out of reach of the heat of the paraffin.
In December 1877 I commenced a series of experiments on
this subject, and these have been continued at intervals since
that time.
The first experiment was an imitation of those of Billroth
and Tiegel (only it was performed antiseptically), and yielded
conflicting results. Thus the liver and kidney putrefied, while
the spleen, muscle, and mesentery remained unaltered.
This being the case, I determined to abandon this method
entirely, and to see if some definite conclusion might not be
arrived at in some other way. The following is a description of
the method I have employed : —
A number of beakers, each provided with a cotton cap, were puri-
fied by heat, somewhat after Mr. Lister's method, and into each vessel
about one-fourth of its volume of pure turnip iut'usioii was introduced
from one of the double-necked Masks (Fig 6, p. 1*J). This was done under
the spray, and the cotton caps were then reapplied. These beakeis
40 THE rARTICULATE THEORY OF FERMENTATION.
were placed in an incubator, and kept at a temperature of 98° F. for
three or four days. At the end of that time the turnip infusion was
clear and unaltered, and the flasks were therefore considered ready for
use.
On January 6tli, 1878, four beakers having been thus jirepared, and
six beakers containing melted pai-affin being also at hand, a healthy
rabbit was iised for the following experiment.
The skin and hair of its abdomen having been thoroughly washed
with 1-20 carbolic lotion, the animal was killed by a blow on the back
of its neck, and the tibdominal cavity was rapidly opened, under a fine
spray of carbolic acid, with purified and heated instruments. Portions
of its organs and tissues were
rapidly cut out and intro-
duced into the beakers,
which were opened in the
spray.
Into the four vessels
containing the pure turnip
infusion portions of liver,
spleen, kidney, and muscle
respectively were intro-
duced, and the caps having
been reapplied while the
flasks were still in the spray,
they were then placed in an
incubator (see Fig. 14).
Into the six flasks con-
taining melted pai-affin por-
tions of liver, kidney,
spleen, muscle, mesentery, and vena cava, with its blood, were dropped
also undei- the spray. The parafl[in was left to solidify, and the
vessels were then placed in the incubator.
All those portions of organs introduced into the turnip infusion
remained ])ermanently puie and free from })utrefaction.'
Of the paraffin beakers, two (muscle and vena cava) remained
without change ; while the other four (liver, spleen, kidney, and
mesentery) putrefied.
In this experiment we have in the first case a series of
' On December 24, 1880, I killed a rabbit and preserved its organs in the
way described here. Fig. :-54, Plate A^, is drawn from a specimen taken from
the beaker containing the spleen, and stained. It will be seen that no organ-
isms whatever arc present.
ANIMAL TISSUES: MY OWN EXPERIMENTS. 47
beakers heated so as to destroy the activity of the dust adhering
to them, and that this was effectually done was proved by the
fact that the turnip infusion introduced into them underwent
no change, although, as has been amply shown in the fore-
going experiments, had ordinary unheated dust been jjresent,
this infusion would have undergone fermentation.
Further, the portions of the tissue are transferred from the
body to the beaker without the possibility of acquiring living
dust, for, as we have seen before, a spray of carbolic acid in an
ordinary atmosphere is able to destroy the fermenting power of
the dust. Such being the case, if the tissue, taken with all pre-
cautions undergo putrefaction, it is possible that the causes of this
fermentation were present in it while in the living body — the
degi'ee of probability depending of course in great measure on
the known skill of the experimenter. But if no change occm-s,
it is proof positive that there were no causes of change present
in the body. In other words, as these unboiled tissues remained
unaltered, it is quite certain that they have no inhei'ent tendency
to undergo fermentation even when freely exposed to air.
I used the turnip infusion partly because I wished to know
whether the beakers had been thoroughly purified, and partly
in order to keep the tissues moist, for I had found in a former
experiment that they dried too rapidly in the open-mouthed
vessel if no fluid were present. Since that time I have used
cucumber fluid, as being more putrescible.
Further, by the use of tliese infusions the conditions favoui-
ing fermentation are greater, for we have here a boiled highly
putrescible infusion of turnip, and an unboiled, if possible still
more putrescible, infusion of meat, as well as the meat itself. It
wei'e hardly possible to provide more favourable conditions for
fermentation. Nevertheless no change occurred.
I may here point out the light thrown by these experiments
on the cause of the want of success in the paraffln experiments.
In the first attempt which I made with tlie paraffln any of the
sup])osed causes of failure might have l)een in 0])erati()n, but in
the experiment just narrat(;d the entrance of aii- laden will)
septic dust into the blood-vessels is excluded because the opera-
tion was done in a spray of carbolic acid. Therefore the failure in
48 THE rARTICULATE THEORY OF FERMENTATION.
the four vessels must have been due to dust in the paraffin, or
to cracking of this after solidification.
But, it may be said, the absence of putrefaction in the
beakers was due to the action of the carbolic acid on the
tissue. This, however, is not the case, for the following
reasons : —
In a preliminary experiment I touched the outside of the
flask (which was of course covered with impure dust) with one
of the portions of the tissue, and afterwards introduced this
piece into the flask, and in it putrefaction occurred rapidly.
Again, the fact that four paraffin flasks went wrong (the organs
being there also subjected to the action of the spray) shows
that this had no influence. Again, when the gall-bladder is
wounded fermentation often occurs. This latter fact is illus-
trated by the following experiment : —
A medium-sized rabbit was killed by a blow on the nape of the
neck. The abdomen bad been washed beforeliand with 1-20 carbolic
acid lotion, and was now rapidly opened under the spray. Into seven
beakers containing pure cucumber infusion, two pieces of liver, one
piece of kidney, one piece of spleen, one of muscle, and one of
mesentery were introduced. In cutting out the liver the gall-bladder
was injured.
Four weeks later, five beakers were unaltered, the two which had
fermented being those containing the pieces of liver, which indeed had
undergone fermentation within twenty-four hours.
I have since met with sevei-al similar instances.
Further, if putrid matter be injected into the jugular vein
of the animal a few minutes before death, all the tissues re-
moved and preserved in the manner described undergo putre-
faction.
I have repeated these experiments many times with like
results,' and I therefore conclude that the tissues of the healthy
' On two occasions I have found that the apparently healthy living tissues,
preserved by the method before described, underwent fermentation and
organisms developed in them. In one case the kidney alone of all the organs
taken, and in another both kidney and liver, miderwent fermentation with
development of organisms, and as I was very careful in performing the expe-
riments, I do not think that this could have occurred from any error in experi-
mentation, and therefore I conclude that the causes of fermentation (micro-
organisms, as we shall afterwards see) were present in the healthy circulating
GENERAL CONCLUSIONS. 49
living body, like the fluids, contain no ferment capable of causing
putrefaction after death, and remain pure in flasks so long as the
dust of the atmosphere is excluded. (In some instances the heart
with its contained blood was also removed, and remained, like
the other tissues, unaltered. Rabbits and cats were the animals
used for the experiments.)
Somewhat similar experiments Avere published in 1878 by
Chiene and Ewart, and they yielded similar results.'
Quite recently,^ Rosenbach mentioned experiments on this
subject performed by Meissner. Meissner was able to preserve
the internal organs of cats and rabbits in contact with boiled
water and pure air, for two to three years, without the occur-
rence of any putrefactive change. He was also successful in
preserving the blood of mammalia, human urine, and g'oat's
milk. The experiments were done with strict aseptic j^recau-
tions, and led him to conclusions similar to the above.
Such, then, are the chief facts at present known with regard
to boiled and unboiled fluids and tissues. We shall add much
to them, and to the support which they give to the views here
expressed, when we come to consider more minutely what is
the nature of the particles which cause putrefaction.
On reviewing the mass of evidence before us we have it dis-
tinctly shown that boiled fluids and tissues have no inherent
tendency to undergo fermentative changes ; that oxygen, whether
pure, nascent, or mixed with nitrogen in the proportions present
in air, cannot cause fermentation, if only the air be previously
passed through such a liquid as sulphuric acid, be heated
strongly, be Altered through cotton wool, be made to enter
very slowly into the flask containing the fluid or allowed to
deposit its dust by gravitation, or be previously acted on by
carbolic acid.
blfiod. That an orgniiif^jn may be present in an active state in tlic circulating
blood need not be a matter of surprise, and need not therefore lead us to the
conclusion that they are always or even generally there, especially as one
single organism would be sufficient to account for the result in each of these
instances. It is indeed surjirising that organisms which must now and then
enter the blood arc so rapidly and surely destroyed.
' Journal of Aiuitonnj and I'Jn/Riolofjy.
■ Uvidschc ZcitH'-hrift fiir C/nrurf/ie, xiii. .'544.
E
50 THE PARTICULATE THEORY OF FERMENTATION.
Thus the material in the air which causes putrefaction is
not a gas, for that would be continuous, and would not be re-
movable by filtration or by rest ; but it is something discon-
tinuous, something heavier than air, something particulate.
These particles may be deprived of their power of causing
fermentation by the action of chemical substances, such as
sulphm'ic and carbolic acids, and also by being subjected to a
high temperatm'e. As they are completely destroyed by heat
(as shown by Tyndall), they are probably of an organic
nature.
And it is not that by boiling these fluids an inherent
tendency to ferment has been destroyed, for, as we have seen,
they possess no such inherent tendency. For not only do
unboiled fluids and tissues outside the body fail to putrefy
when protected carefully from dust — they also undergo no
change, as indeed necessarily follows from the foregoing, when
confined in natural or artificial cavities in the living body.
Who is not acquainted with the behaviour of blood when ex-
travasated into the tissues or cavities of the living body so long
as it is not exposed to the outer world ? We all know what
a large amount of effused blood may be present about the
ends of a fractured bone without decomposition occurring in it,
and the same is the case in the hemorrhages into joints in
hemophilia, hemorrhages within the skull, &c. And we also
know what frequently happens if we cut into any of these
extravasations and admit dust-laden air into them. The blood
which we found odourless, and it may be clotted, may become
in a few hours a foul- smelling liquid ; it has, in fact, putrefied,
just as it may do when kept in a flask without exclusion of dust.
And just as in the case of blood, so with other fluids. Hy-
drocele and serous effusions remain unaltered so long as they
are kept from the dust. Examine the pus from a chronic
abscess, and even though that abscess be connected with carious
bone, it will be found to be odourless and bland, and if carefully
received into pure flasks, will, just as in the case of blood,
remain odourless and apparently unchanged for an indefinite
length of time. (I shall give later on the explanation of the
cases where the pus of acute abscesses, when let out, is found to
have a foul smell, as is sometimes the case in acute necrosis.)
CONCLUSIONS. 51
And not only is this the case with fluids, it is also the case
with tissues in the living body. In a fractm-e many portions
of the tissue are cut off from their vascular supply, or killed by
the violence causing the injury, and yet they do not decompose ;
they are not separated as sloughs — they disappear by absorption.
Yet if the same injury be not subcutaneous and the injured
parts be exposed to ordinary air, they putrefy, and come away in
a few days as sloughs.
So in infarcts in internal organs, the tissue in the region of
the infarct dies, but does not putrefy — does not slough ; while
when death of the integuments occurs, putrefaction and slough-
ing follow, for here the dead tissue is exposed to the dust of
the atmosphere.
Similarly, in the case of wounds, when a piece of skin is cut
away and an open sore is left, the blood and serum which col-
lect in that sore ferment, in all probability putrefy, because the
air admitted to them was not heated air, not filtered air, was
air which had not been acted on by suitable chemical sub-
stances.
The causes of fermentation are therefore solid particles, pro-
bably of an organic nature, which are present in varying quan-
tities in the surrounding air, and which are deposited as dust
on all surrounding objects.
It is thus evident that in order to prevent putrefaction it is
only necessary to prevent the access of these particles, or, if
this cannot be done, to destroy their fermenting power in some
way or other before they reach the wounds — as, for instance, by
the use of carbolic acid.
It is on this principle that Aseptic Su7'gery,^- as introduced
by Mr. Lister, is based.
' The term ' aseptic ' is the best to indicate this form of antiseptic surgery,
because, as we siiall see, there are many different forms of treatment which
come under the term 'antiseptic,' while this is the only one which can truly
bear the name 'aseptic' In other words, there are many methods by which
the occurrence of putrefaction is more or less interfered with, but they all act
on a more or less imperfect principle, with the exception of that introduced
by Mr. Lister, which, founded on a true principle, attains the ideal of results
— viz. a complete absence of putrefaclion— an asepsis. His methcd, then, is
best designated by the term expressing its result — Aseptic.
E 2
52 ASEPTIC SURGERY— MATERIALS EMPLOYED.
CHAPTER in.
ASEPTIC SURGERY MATERIALS EMrLOYED.
Problems to be solved in order to keep a wound aseptic : Carbolic acid —
CarhoUc lotions — Pure carholic acid — SoUttioitin metliylated sjnrit — carbolic
oil — Carbolic acid and glycerine: Sj^ray producers: Catgut — Carholiscd
catf/ut — Mr. Lister's carholiscd chromic catgut — Dr. MacEwen's chromic
catgut— Ca-tguttrough and pocltet caxe: Carbolised silk : Protective: Carbolic
gauze — Composition — 3Iethod of preparation — Von Bruns'' gauze: Mac-
intosh : Sponges : Boracic acid — Boracic lotion — Boracic lint — Boracic
ointm-ent: Salicylic a-cid— Salicylic acid cream — Salicylic ointment : Chlo-
ride of zinc : Iodoform : Carbolised cotton wool.
Aseptic surgery is based on the piinciple first enunciated by
Mr. Lister, and indicated in the preceding pages ; viz. the
exclusion of active ferments from the discharges of wounds.
Theoretically, this is the ideal form of antiseptic surgery, for
here, supposing that the attempt is successful, the causes of
putrefaction do not enter the wound in a state capable of pro-
ducing fermentation, and therefore decomposition of the dis-
charges, or of dead portions of tissue, &c., cannot 2:)0ssibly
occur.
The problem which Mr. Lister sought to solve may be
shortly stated as follows : —
On all objects in the external world septic dust is present —
on the skin of the patient, on the hands of the surgeon and
his assistants, on all instruments, in water, in the air, &c. ;
and when a wound is made any introduction of this dust
must be carefidly avoided. Then after the wound has been
made, care must be taken to prevent its entrance during the
after-treatment. Some sort of dressing must be provided
which shall prevent its passage in an active state, and at
each change of this dressing the problem is the same as at
the time of infliction of the wound. Such being the question
CARBOLIC ACID. 63
at issue, I must now proceed to the modes in which it has been
answered.
I shall first enumerate the substances employed in aseptic
surgery.
Carbolic Acid is the antiseptic employed to destroy the
particles in the air and on surrounding objects which give rise
to putrefaction. It is obtained in the solid state and of ex-
treme purity from Bowdler and Bickerdike, Church, Lancashire,
who give it the name of Absolute Phenol. It is used in various
forms.
The Cai'bolic Lotions used are of two strengths — 1 in 20
and 1 in 40 ; one part of crystallised carbolic acid dissolved in
20 or 40 parts of water respectively. The solution is kept in
a stoppered bottle in order to avoid evaporation of the acid. It
ought to be quite clear ; when it is not so, and more especially
when globules of oily matter are present, it is impure, the
oily particles consisting of cresylic acid. It is a mistake to add
alcohol or glycerine to aid the solubility of the acid, because
these substances hold the acid more tenaciously than water, and
it is thus not so potent for producing an instantaneous effect.
Undiluted Liquid Carbolic Acid may in some cases be
required. This is obtained by liquefying the crystals by the
addition of a few drops of water. This is chiefly used for
injecting naevi, varicose veins, vtc.
A solution of carbolic acid in methylated spirit or in recti-
fied spii-it, in the proportion of 1-5, is used for the purpose of
purifying wounds inflicted some twenty-four or thirty-six hours
before coming under treatment.
Carbolic Oil is employed in various proportions, generally
1 in 5, 1 in 10, and 1 in 20, consisting of carbolic acid mixed
with olive oil in the foregoing proportions.
Carbolic oil 1-5 is but rarely used, tliough it is occasionally
applied as a dressing to foul wounds, for the purpose of purify-
ing them. It is chiefly known as the solution in which catgut
is permanently preserved.
Carbolic oil 1-10 is used as a dressing for wounds in the
neighbourhood of the anus, penis, &c.
Carbolic oil 1-20 is used for oiling catheters or other in-
64
ASEPTIC SUROERY^MATERIALS EMPLOYED.
struments before introducing them into tlie bladder. Carbolic
acid of this strength does not seem to be too irritating for the
Fig. 15.— Hand spray producer.
mucous membrane of the urethra, while it apparently secures
against the introduction into the bladder of matters which are
capable of causing putrefaction.
There are various objections
to these oily dressings. The chief
are, that the carbolic acid is very
rapidly washed out by the dis-
charge, and that they are very
dirty, and soon spoil india-rubber
tissues.
The latter disadvantage is got
rid of by the use of carbolic acid
and glycerine in the proportions
of 1-5 and 1-10. This is now
employed as a dressing in the cir-
cumstances in which the oil has been generally used.
A sjjray of carbolic acid is generally employed in order to
purify the atmosphere. This is obtained by driving a rapid
Fig. 16.— The ordinary steam
spray producer.
CARBOLIC ACID SPRAY.
55
current of air or steam through a horizontal tube so as to pass
over the orifice of a more or less vertical one. In this way a
vacuum is produced in the vertical tube, and the fluid at its
lower end rises, and is expelled from the orifice in the form of
spray. We have two forms of spray : one in which air is
Fig. 17,
Steam spray producer, showing the lamp at present
IN USE.
It consists of a small flamo, which plays on a plate of metal attached to a hollow central tiibe
containing a wick, and perforated by holes at the top. The heat is communicated to tlie wick
—the spirit volatilises, and Inirns as it escapes from the top of the tube. The hole in the plate
allows the flame of tlje snjall wick to pass up and li^■ht the spirit vapour, which jiasscs out through
the holes at the top of the central tube. The cap, which is jjlacfd over the lamp when not in use,
and the boiler and vessel for the carbolic acid, are indicated by dotted lines.
driven over the vertical tube — hand or foot sprays ; and the
other in which steam is employed — steam sprays. The hand
or foot sprays produce a somewhat coarse spray, and the force
required is such as soon to exhaust the individual employed.
They are therefore very uncertain implements, and have now
entirely given place to the steam spray.-;, where there is a steady
current as long as the water in the boiler lasts. When the
hand s])rays are emi)loypd 1-40 solution is placed in the bottle.
50
ASEPTIC SURGERY— MATERIALS EMPLOYED.
In the steam spray the 1-20 solution is used because the steam,
mixing with the solution, reduces its strength to 1-30 or 1-35.
I need not describe here the steam spray apparatus, more
especially as it can be easily obtained, of Mr. Lister's pattern,
from David Marr, 27 Little Queen Street, Holborn. These
sprays consist of the following parts : — A boiler which contains
water, and which is heated by a spirit lamp placed beneath it.
The steam issues through a tube placed at an angle to another
more upright one, through which the carbolic acid lotion 1-20,
which is placed in the glass
retort, is sucked up. This
1-20 lotion, mixing with the
steam, makes a solution of 1-30
to 1-35. The carbolic acid
solution passes through a
sponge at the bottom of the
upright tube, which filters it,
and thus prevents the minute
orifice of the tube from be-
coming choked up by coarse
particles. These sprays are of
various sizes, and the largest
ones have two nozzles, which
may be vised singly, or to-
gether where the field of operation is large as in ovariotomy.
The catgut used for tying the vessels is prepared in the
following manner : — Ordinary catgut as obtained from the
shops, when introduced into blood-serum, soon swells up and
becomes weak. At the same time it is very slippery, and a
knot will not hold ; and when placed in the tissues it very
rapidly becomes absorbed. With the view of obviating these
defects it is prepared by placing it in a solution of carbolic acid
in oil (1-5) with a very small quantity of Avater (10 per cent.)
diffused through the oil. As the water ultimately falls to the
bottom, a few pebbles are placed on the bottom of the vessel, on
which the catgut rests. It does not then come in contact with
the water. As a result of keeping it in this solution, the
catgut first becomes supple and soft, but afterwards harder and
firmer, and is then al)le to resist the action of the fluids and
Fig. 18.— Large steam spray riio-
DUCER WITH DOUBLE NOZ/LE FOR
OVARIOTOMY, ETC,
CATGUT. 67
tissues for a considerable time. It is kept in this fluid for six
or eight months, and is then transferred to the ordinary 1-5
oily solution. The longer it is kept in this solution the better
it becomes. The rationale of this method will be found in
^Mr. Lister's paper in the ' Lancet ' of Feb. 5, 1881.
Quite recently ^ jNL-. Lister has published a new method of pre-
paring catgut, by means of which a stronger article is obtained,
and one not absorbed nearly so soon as the old kind. It also
possesses an advantage over the old kind, in that it disappears
by erosion of the surface, and does not become infiltrated with
cells, as is the case with the ordinary forms. It thus remains
as a firm constricting band, till it is completely replaced by new
tissue. I cannot do better than quote JVIr. Lister's description
of the method by which this gut is prepared : ' I dissolve one
part of chromic acid in 4,000 parts of distilled water, and add
to the solution 200 parts of pure carbolic acid, or absolute
phenol. In other words, I use a 1-20 watery solution of
carbolic acid — only that the carbolic acid is dissolved, not in
pure water, but in an exceedingly dilute solution of chromic
acid. But, minute as is the quantity of the chromic acid, it
exerts, when in conjunction with carbolic acid, a most power-
ful effect upon the gut. The first effect of the addition of
the carbolic acid to the chromic solution is to change its pale
yellow to a rich golden tint. But if the liquid is allowed to
stand without the introduction of the catgut, it changes in the
course of a few hours to a dingy reddish-brown, in consequence
of some mutual reaction of the two acids ; and a considerable
amount of reddish grey j)recipitate is formed. If, however,
catgut about equal in weight to the carbolic acid is added as
soon as the ingredients are mixed, the liquid retains its bright-
ness, and the only change observed is the gradual diminution of
the depth of the yellow colour; the precipitate, which I pre-
sume still occurs, taking place into the substance of the catgut.
As soon, therefore, as the preparing liquid has been made, cat-
gut equal in weight to the phenol is introduced into it. If
you have too large a ]»roportion of catgut, it will-not be suffi-
ciently ])repared; if you have too small a (juantity, it may run
the risk of being over-prepared. At the end of forty-eiglit
' Lancet, Feb. 5, 1881.
58 ASEPTIC SURGERY— MATERIALS EMPLOYED.
hours the chromic element of the liquid has nearly spent itself,
and precipitation is complete. The catgut is then taken out
of the solution and dried, and when dry placed in 1-5 carbolic
oil : it is then fit for use. . . . The preparing liquid causes
a certain amount of softening of the catgut, and if it is intro-
duced in loose hanks, this will tend to produce a little uncoil-
ing of the twisted cord, and a still greater degree of uncoiling
will take place during drying. It is of very great importance
that this should not occur, because it involves weakening of
the thread, and that in different degi'ees in different parts ; and
this may lead to the gut giving way when you subject it to
a strain. The catgut then should be prepared on the stretch,
both when it is put to soak and when it is put to dry.
' I need not enter into the mode in which this can be done
by the manufacturer. I may only say this, that the surgeon
who wishes to prepare it himself may do it in different ways.
For instance, he may take two large test-tubes, one a little
larger than the other, and he may wind the catgut on the
smaller tube, fixing one end by sealing-wax, winding it round,
and then bringing it up again, and fixing the other end with
sealing-wax at a higher level than the liquid will reach, putting
sufficient liquid into the larger test-tube, and introducing the
smaller test-tube with the catgut wound round it, with a little
shot to keep it down in the liquid. After forty-eight hours, he
takes out the smaller test-tube, and leaves it till the catgut is
completely dry. I merely mention this as an illustration, and
also as furnishing a hint to some surgeons in private practice
who may desire to prepare the catgut themselves ; or a couple of
gallipots, one larger than the other, will do just as well. But,
as I have said, the principal uncoiling takes place during drying ;
and for all ordinary purposes a sufficiently good article is got by
putting the catgut loose into the liquid, and making it dry on
the stretch by tying the ends of each hank to two fixed points
in a room.' Erosion of this catgut does not begin till about a
fortnight after its introduction into the tissues.
Dr. MacEwen has lately brought forward a somewhat
different method of preparing catgut.' ' These ligatures are
prepared by making, first, a watery solution of cliromic acid, one
' Britisli Medical Journal, Jan. 2'.), 1881.
CATGUT.
59
to five ; then one part of this solution is added to twenty of
glycerine. This forms a dark greenish compound, in which the
hanks of catgut are inserted and retained for seven or eight
months, the bottle containing them being occasionally shaken.
At the end of this time the catgut acquires a semi-translucency,
and has a dark colour like preserved ginger. It is then ready
Fig. 19. — Trough for catgut.
for use, and is stored in a solution of carbolic acid and glycerine
(one to ten).' Ligatures so prepared begin to soften on an
average about the fourteenth day, and are more or less com-
pletely absorbed the twentieth day.
A very convenient method of keeping catgut for use in
hospital is to wind it round reels, say three, each holding a
different thickness of gut, which are suspended in a vessel
X._^
V ^
^ ^'
-^^^^
Fig. 20. — Lister's pocket catgut holder.
A, HoMcr complete. B, The reel on which the catgiit is wound.
containing carbolic oil 1-5 (see Fig. 19). The lid of the box
is perforated with holes through which the ends of the catgut
pass. In this way the gut may be taken directly from the
oily solution without any trouble.
In order to have a supply of gut always at hand, jNIr. T.,ister
has devised the catgut holder shown in the accompanying figure
(P^'ig. 20). The gut is wound on a reel which is carried in a
German silver case. There is no necessity to fill tin's case with
60 ASEPTIC SURGERY— MATERIALS EMPLOYED.
carbolic oil, as is done by some surgeons. Sometimes the case
is combined with a caustic holder at the other end.
Carbolised Silk is often used for sutures, and is prepared
as follows : — Nine parts of beeswax and one part of carbolic acid
are melted together. Silk thread of various sizes is steeped
for some minutes in this mixture, till it is thoroughly impreg-
nated with it. As the thread is taken out, it is drawn through
a cloth in order to remove the superfluous wax. The wax holds
the carbolic acid, makes the thread more useful, and fills up to
some extent its interstices, thus preventing it from becoming
soaked with fluids. The carbolised silk thus prepared is kept
permanently in stoppered bottles, or wrapped in carbolic gauze.
It must- not be steeped for any length of time in the lotion
before being used, because the threads become opened out. If
the thread be properly kept, the interior is aseptic or even anti-
septic, and passing the thread through the fingers moistened
with carbolic lotion, or a momentary immersion in 1-20 car-
bolic solution, is sufficient to destroy any septic dust adhering
to its exterior.
In order to protect healing wounds from the irritation of
carbolic acid a special material is employed termed the Protec-
tive. This consists of oiled silk coated with copal varnish.
When this is dry a mixture of one part of dextrine, two parts of
powdered starch, and sixteen parts of cold watery solution of
carbolic acid (1-20) is brushed over the surface. The rationale
of this method of preparation is the following : — Oiled silk alone
is better for the purpose of a protective than gutta-percha
tissue, because carbolic acid does not so readily pass through it.
It does, however, do so, and therefore copal varnish, which is
almost absolutely impermeable to carbolic acid, is added. As,
however, the fluid collects on this as on a duck's back, leaving
intervals between each drop on which dust may fall and escape
the action of the acid, the dextrine solution is added, and the
result is, that when moistened the whole surface of the protec-
tive remains imiformly wet. The use of the carbolic acid in
the dextrine solution is not to add any carbolic acid to the pro-
tective, but because it is better than water for enabling the
dextrine to adhere to the varnished oiled silk. For the same
reason the ])owdered starch is added. The original carbolic
CARBOLIC GAUZE. 61
acid flies off very quickly from the protective, leaving a material
containing no antiseptic in its substance.
Garholic Gauze is the material generally employed as a
dressing to guard against the entrance of causes of fermentation
into a wound after an operation. The gauze used is ordinary
fine unbleached tarlatan washed and dried. There are various
methods of impregnating this gauze with carbolic acid. I will
give Mr. Lister's description of a simple method, w^hich can be
used in any hospital, and which was recently employed during the
Russo-Turkish war for making fresh gauze in camps. ^ The
mixture employed for charging the gauze was originally one part
of carbolic acid, five parts of resin, and seven parts of paraffin.
Lately the formula has been changed to one part of crystallised
carbolic acid, four parts of common resin, and four parts of
paraffin. These materials, mixed together, are added to an equal
weight of unprepared gauze. ' In order to charge the gauze,
the paraffin and resin are first melted together in a w^ater
bath, after which the acid is added, and blended by stirring.
The object now is to diffuse this melted mixture equally
through the cotton cloth, and for this purpose two things are
requisite, viz. that the cotton be at a higher tem})erature than
the melting point of the mixture, and that it be subjected to
moderate pressure after receiving it. The cotton cloth, a yard
wide, is cut into six-yard lengths, and these having l^een folded
so as to be half a yard square, are placed in a dry hot chamber,
formed of two tin boxes placed one within the other, with an
interval to receive water, which is kept boiling by fire or gas
beneath, the upper edges of the boxes being connected and
provided with an exit pipe for the steam. There is also a
glass tube arranged as a gauge of the amount of the water,
and the chamber has a properly fitting lid The bottom of
the chamber is strengthened with an iron plate, to enable it
to bear the weight used for compressing the gauze when
charged. There is a piece of wood about two inches thick
nearly fitting the chamber, covered with sheet lead, so as to
make it about as heavy as a man can lift by means of two
handles in the upper fjurface. The weight is lieatcd along
with the cotton, and is puf, ^rst into the cl;:imber so as to leave
' See Lancet, Marcli 13, 1875.
(i2 ASEPTIC SURGERY— MATERIALS EMPLOYED.
the cotton loose for the penetration of the heat, which occupies
two or three hours. The cotton when heated is taken out of
the chamber along with the weight, and placed in a wooden box
to protect it from the cold. (It would be better to have a
second hot chamber for this purpose, since in cold weather the
cotton is apt to be too much cooled in spite of the protection of
the wooden box.) The heated gauze is then at once charged
with the melted mixture of carbolic acid, resin, and paraffin, in
quantity equal to the weight of the cotton fabric (or slightly
less), and in order to diffuse the liquid as equally as possible, it
is sprinkled over the gauze by means of a syringe, with a
number of minute perforations in its extremity, the body of the
syringe and the piston-rod having each a wooden handle to pro-
tect the hands of the workman from the heat. The syringe is
constructed to hold half the quantity of the mixture required
for charging one piece of cloth. One folded piece being placed
at the bottom of the hot chamber, its upper half is raised and
turned aside, and one syringeful is sprinkled over the lower half.
The upper half is then put back into position, and another
syringeful thrown on. The same process is repeated with all
the other pieces of gauze, after which the weight is put into the
chamber to compress the charged cotton, and the lid applied.
An hour or two are then allowed to elapse, to permit the com-
plete diffusion of the liquid, when the material is fit for use.
The apparatus above described can be made by a common tin-
man for about lOL' Fig. 21 shows the apparatus employed in
the Griasgow Infirmary. •
As the muslin is the dearest item in the gauze Mr. Lister
has suggested that the dressings should be washed and the
gauze recharged. The larger dressings are therefore kept and
sent back to the manufacturer, who washes and recharges them.
This recharged gauze can then be used as loose gauze in future
dressings.
In this gauze the carbolic acid is the only active agent ; the
resin is used to hold the acid — i.e. to prevent it from being
washed out too soon by the discharge — while the paraffin is
employed to lessen the adhesiveness of the resin. The gauze
' See ' Practical Papers on the JIaterials of the Antiseptic Method of
Treatment.' I'y George lieatson. Glastjow Medical Journal, March 1880.
CARBOLIC GAUZE.
63
ought to be kept in a tin box, closing tightly to prevent
evaporation of the carbolic acid. It is used either in the form
of loose gauze or folded dressings and bandages.
A great many different ways of preparing gauze have been
published, but none are so good as that just described.
Von Bruns has lately recommended a gauze containing
castor-oil instead of paraffin.
His formula is —
Carbolic, acid
Resin
Castoi--oil
Spirit
1 part
4 parts
8 „
20 „
Fig. 21. — Machine used in the Glasgow royal infikjiary for
manufacturing gauze.
A is tlie receptacle for the antiseptic mLxture of carbolic acid, resin, and paraffin ; E is the tin
case in whicli the muslin is heated, impregnated with the mixture, and submitted to pressure.
IJ is a pipe whicli conveys steam for heating the apparatus, and E E are stopcocks for turning
on or shutting off the steam in connection with either A or B. (From Dr. Beatson's ' Practical
Papers on Antiseptic Surgery.')
The resin is first dissolved in the spirit, then the carbolic
acid and castor-oil are added. The gauze is simply soaked in
this, and then hung up to allow the spirit to evaporate. The
objection to this gauze is that the castor-oil interferes with the
affinity of resin for carbolic acid, and thus the carbolic acid will
be sooner washed out, «ind the gauze thereby rendered less
trustworthy.
In order to prevent the discharge from soaking directly
through the dressing macintosh cloth is used. This is
cotton cloth with a thin layer of india-rubber spread on one
64 ASEPTIC SURGERY—MATERIALS EMRLOYED.
side. It is placed outside the gauze dressing. As a rule one
layer of the gauze comes outside it, partly in order to keep it
in position, and partly also, in case any hole should exist in the
macintosh, to have a little antiseptic material outside. Care
is taken that the side on which the india-rubber is spread goes
next the wound, for if the other side be placed inwards it absorbs
discharge, and, not being itself antiseptic, it becomes in reality
a piece of impure cotton in the interior of the dressing, and
may thus communicate putrefaction inwards. The macin-
tosh itself also gets spoilt when so used. The dressing con-
sists of a piece of gauze of sufficient size folded in eight layers,
beneath the outer layer of which the mackintosh cloth is
placed.
Sponges are washed after an operation, and are then kept
soaking till required in a jar containing carbolic acid 1-20.
During an operation they are washed in 1-40 carbolic acid
lotion.
These sponges often become filled with fibrin, and thus
rendered more or less useless. It is very difficult to remove
this fibrin by washing. Mr. Lister, therefore, after an operation
places the sponges in a tank containing water. Putrefaction
of the fibrin occurs, and after some days the sponges can be
easily cleansed. They are then placed till required in the
1—20 carbolic solution.
When the wound becomes quite superficial, various prepar-
ations of BoKACic Acid may be employed with advantage.
Boracic lotion is a cold saturated solution of boracic acid
(BgOgSHgO) in water. This acid is soluble in 25 to 30 parts
of cold water, and in very much larger proportion when the
water is boiling. It is convenient to tinge this solution with
litmus in order to distinguish it from the carbolic lotions.
Boracic lint is ordinary surgical lint soaked in a hot saturated
solution of boracic acid and then hung up to dry. About half
its weight consists of crystals of the acid. This is also stained
with litmus.
Boracic ointment is employed in certain cases. Two
strengths are commonly used, called full strength and half
strength ; the former being applied to wounds where cavities
exist, the latter to superficial wounds which one wishes to heal
SALICYLIC ACID. 65
rapidly. The following is the original formula for the full
strength ointment : —
Boracic acid crystals ..... 1 part
White wax ....... 1 „
Paraffin ........ 2 parts
Almond-oil ....... 2- „
First mix the wax and paraffin by heating them together,
then add the oil ; mix the crystals with this in a warm
mortar, and continue the process of mixing till the liquid
solidifies. Spread on thin cotton cloth.
The half strength contains half the quantity of boracic acid.
A much softer and more manageable boracic ointment is
now made with vaseline. The following is the best formula : —
Make a basis of 2 parts of paraffin to 1 part of vaseline.
Take of this o parts
„ boracic acid, 1 part. Mix.
Salicylic acid cr'eam is used for applying around a wound
when a dressing is to be left on for some days. It prevents
irritation by the discharge. It formerly consisted of salicylic
acid crystals mixed with 1-20 carboh'c acid lotion in sufficient
quantity to form a creamy fluid. This is apt to separate into
two layers, and therefore it is better to make a cream by mixing
salicylic acid with glycerine so as to form a paste. This latter
cream remains of uniform consistence, and is easily applied. For
this purpose Mr. Lister uses glycerine and carbolic acid 1-10.
The' formula for salicylic oinhnent is —
Of the same l^ase as is used for boracic acid . 29 parts
Salicylic acid ....... 1 part.
For the purpose of purifying sinuses, putrid ulcers, &c., a
solution of chloride of zinc is used of the strength of 40 grs.
to the oz. of water. This is either apjdied on lint to the whole
surface of a wound, or it is injected by means of a syringe and
catheter into all the deep parts of the wound, care being taken
to provide free exit for the fluid injected. If the exit of the
solution is obstructed, it may pass into the tissues and cause
gangrene.
lodofoivi is now applied to the surface of ulcers, and
F
66 ASEPTIC SURGERY— MATERIALS EMPLOYED.
answers the same purpose as the chloride of zinc solution, while
it causes no pain.
Carholised cotton ivool is used in some cases of gangrene.
It is obtained by soaking pure cotton wool in a 1 per cent,
solution of carbolic acid in ether. The cotton is then dried and
used immediately.
DESCRIPTION OF AN ASEPTIC OPERATION.
CHAPTER IV.
ASEPTIC SURGERY (continvcd).
Example of an aseptic operation : Purification of the skin — Fingers — Instru-
ments : Spray — Precautions — Probable errors, and mode of remedying
them : Guard : Ligature of arteries : Drainage of wounds — India-rubber
tubes — Catgut drains — Horse hair — Decalcified bone tubes (Neuber's and
MacEwen's) : Sutures ; Button stitches — Stitches of relaxation — Stitches
of coaptation — Aseptic strapping — Protective : Deep dressing : Loose
gauze : Gauze dressing : Elastic bandage. Changing the dressings —
Time— Method. Treatment op ulcers : Purification of the sore : Boracic
dressing : Boracic and salicylic ointment : Boracic poultice.
Having described the materials employed in aseptic sm-gery,
we must now consider how they may best be employed. Take
as an example of an operation the removal of a fatty tumonr.
The patient having been brought under the influence of
chloroform or other amesthetic, the skin over the tumour, and
for some distance in the vicinity, is thoroughly pmified from
any active dust by washing it well with a solution of carbolic
acid 1-20. The surgeon and his assistants also wash their
hands in 1-40 carbolic lotion, while the instruments are put to
soak in 1-20. A towel is arranged close to the tumour, gene-
rally on the part of the table between the operator and the
patient, which towel has been well soaked in 1-20 carbolic
lotion, and is meant as an antiseptic basis on which instruments
may be laid during the course of the operation without any
fear of their contamination. This towel is so arranged as to be
within the cloud of spray. A spray being now made to play
over the i)art from a convenient distance, the surgeon makes his
incisions, removes the tumour, ties the vessels with catgut,
introduces a suitable drain, stitches up the wound, and a])i)lies
a piece of protective but little larger than the wound — the pro-
tective being of course dipped in the 1-40 carbolic solution.
p2
68 ASEFTIC SURGERY.
Outside this is applied a piece of wet gauze, consisting of
several layers of loose gauze which has been soaking for some
time in the 1-40 carbolic solution. This wet gauze and pro-
tective are called the deep dressing. The wet gauze must
overlap the protective in all directions. Then any remaining
hollow is filled up with loose gauze, and outside the whole a
gauze dressing is fixed. This dressing consists of a piece of
carbolic gauze of suitable size, folded in eight layers, and having
the macintosh placed beneath the outermost layer, with the
india-rubber side inwards. The dressing is fixed by means of a
bandage, and when this is accomplished the spray may be
stopped. Then around the edge of the dressing an elastic
bandage is applied so as to keep the edge constantly in contact
with the body, and to allow no interval to occur between the
dressing and the skin during the movements of the patient.
The elastic is carefully fixed to the edge of the dressing by
means of safety pins.
In the after progress of the case the dressing is changed
according to the amount of discharge, though in no instance
is it left longer than eight days.
Such is, very briefly, a sketch of the ordinary method of
performing operations aseptically. I shall now consider each
step in detail, and point out the most frequent sources of
failure in carrying out the method ; for it must always be
borne in mind that the whole operation, as far as regards the
avoidance of putrefaction, requires as much care as if it were an
experiment performed in a laboratory on putrescible fluid con-
tained in glass vessels.
The first thing, then, is to purify the skin in the neigh-
bourhood of the seat of operation. This is necessary, because
the skin is covered with dust. The natural grease of the skin is
not easily removed by simple washing, and it protects the septic
particles present beneath it and in the hair or sebaceous follicles.
This purification of the skin is carried out by washing it well
with 1-20 carbolic lotion, the antiseptic being allowed to act
for some little time. It is well, having first washed the neigh-
bourhood thoroughly, to apply over the seat of operation a
large rag or towel soaked in 1-20 solution, and to allow this to
remain on the part for some minutes. Where the epidermis
PURIFICATION OF THE SKIN. 69
is thick, or where there is any putrid matter present, it is best
to apply this towel about half-au-hour before the operation. It
is not necessary to wash the skin with soap and water, or with
alcohol or ether, as is often done in Germany. The carbolic
acid has a wonderful power of penetrating grease or epidermis ;
and if time be given for it to act it is unnecessary to wash off
the grease beforehand. If the wound is to be in the neigh-
bourhood of hair, as in the axilla or near the pubis, the part
must be shaved, and then well soaked with the carbolic lotion.
The errors in the purification of the part may be that the
skin is not purified at all, or that it is washed with water ; or,
as I have seen, the operator simply allows a carbolic spray to
play over it for a minute or two, and is satisfied with this ; or
he merely rubs the siuface with his wet finger. This purifica-
tion must, however, be done thoroughly, for every hair follicle
and gland duct may contain causes of putrefaction. Carbolic
oil is used by some instead of the watery solution to purify the
skin. This is a great mistake, for oil has a much greater
affinity for carbolic acid than water has, and therefore the
carbolic acid in the oily solution does not act with the same
rapidity as the watery solution. Thus 1-20 or even 1-10 car-
bolic oil is not nearly so useful for producing an instantaneous
effect as 1-20 carbolic lotion.
At the same time the operator and his assistants purify their
hands. This must also be done thoroughly, and the folds of
skin about the nail more especially must be well cleansed with
the lotion. In an important operation, as in an o})eration on
a joint, it is well to use 1-20 carbolic lotion for this purpose,
so as to avoid any chance of a lurking particle ; but in ordinary
operations 1-40 is quite sufficient. This purification of the
hands is only too apt to be a sham, no care being taken about
the nails and folds of skin. The 1-20 is not used in all cases,
because 1-40 is really sufficient, and the stronger solution is
apt to benumb the hand.
The instruments are purified by immersion in 1-20 carbolic
lotion before theojjeration. A tin or jxHcelain trough filled with
the 1-20 solution is employed for tliis purpose, the instruments
being placed in it souk; time liefore an operation (l*'ig. 22).
The instruments are not merely dipped ; they must remain in
70
ASEPTIC SURGERY.
the lotion for some time, because the carbolic acid requires a
little time to act on the grease or dirt on them. For the same
reason the teeth of toothed instruments ought to be cleaned
thoroughly, and forceps locking by catches ought to be widely
opened, so as to allow the solution to come in contact with all
parts. The whole instrument must be immersed, for if only the
point be purified it may happen that the impure handle is in-
advertently brought into contact with the wound during the
course of the operation.
The errors most likely to occur are either that during the
course of the operation an instrument not previously in the tray
is used without any attempt at purification, or that the instru-
ment is imperfectly purified or only part of it cleansed. I have
seen the danger of partial purification more than once exem-
FlG. 22. — I'DRCELAIN TROUGH CONTAINING INSTRUMENTS SOAKING IN
CARBOLIC LOTION.
plified. Thus I have seen the blade of a knife alone purified,
and the surgeon in the middle of the operation use the unclean
handle to separate the tissues. Other errors in the manipu-
lation of instruments will be referred to presently.
The spray is very important in many cases, for it provides
an atmosphere in which instruments, &c., may be kept without
danger of contamination. In order to have a wide and large
antiseptic area in which to work, the spray ought not to be too
near, about six or eight feet or more being a suitable distance
for a good spray. Care must be taken that the spray is not
blown off the part by draughts or by people moving about. The
spray is most necessary in opening abscesses or in stitching up
wounds, for, to take the latter case, as the wound is not syringed
SPRAY
71
out after the stitches are inserted, septic air may be inclosed
in the cavity of the wound, and may give rise to putrefaction if
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the spray has not been playing over the wound while the
stitches were being introduced.
During the course of an operation any instrument which has
been once purified, if kept in the spray, even though covered'
with blood, remains piu*e, and may be introduced into the
ASEPTIC SURGERY.
wound without hesitation. The same is the case with the
hands of the operator or assistants ; and therefore the dresser, in
handing instruments to the surgeon, if)iust hand them into
the spray (Fig. 23). If in the course of the operation the
surgeon reaches his hand or an instrument out of the spray
for any reason whatever, it must be repurified before being
put into the wound. For this purpose there is generally a
Fig. 2i.— To show the arrangement of towels, etc., in a large
OPERATION.
a a a Are tliree towels which have been soaked in 1-20 rarholic lotion, so that inatruments, &c.
may be placed on them without fear of contamination. Tlm^ a small sponse will be seen on the
upper one. d is tlie dish containing 1-40 carbolic lotion wliioli alwavs stands before the oiicrator,
and in the line of tlie spray. In this he places the instruments which are not being used, and
in it lie rcpurifies his hands or instruments if they have been removed from tlie elonil of spray.
In tliis particular instance we have a lar^e wound to deal with— one so large that a single spray,
unless of large volume, may not cover it completely. Hence a piece of gnai-d soaked in carbolic
lotion Is thrown over the front of the wound while the surgeon is attending to the axillary part,
or rice versd.
basin of 1-40 carbolic lotion placed close to the operator in the
line of the spray, in which fingers, instruments, &c., may be
re-purified by momentary dipping. When instruments are laid
down out of the spray, or, in the spray, on a blanket, they
must be repurified before being used again. To provide a basis
on which instruments may be laid, the carbolised towel is
arranged before the operator as formerly described, and the
blankets in the neighbourhood are generally also covered up
SPRAY, 73
with wet towels, so as to avoid the chance of the instruments
being laid on the blankets (see Fig. 24). Should the operator,
during the course of an operation, wipe his hands in a dry towel,
or touch any unpurified substance, he must remember to wash
his hands in 1-40 carbolic lotion before re-introducing them
into the wound.
These precautions seem on the one hand self-evident, while
on the other they seem so burdensome to remember that
they are often neglected by self-sufficient surgeons. And yet
it is by the neglect of these, rather than by error in any other
part of the Listerian method, that mistakes arise and failures
occur. Many people think that the spray is the essential part
of the treatment, and neglect the precautions as to constant
purification of instruments, &c., and when their cases go wrong
they say that the principle is incorrect. And yet one thoroughly
acquainted with the Listerian method will readily detect the
loopholes, and the general loophole is the omission of some of the
precautions with regard to purification of fingers, instruments,
&c. Thus I have seen a surgeon with considerable experience
in aseptic treatment, during the com-se of a difficult operation
wipe his hands with a dry towel and immediately introduce
them, covered with the dust from the towel, into the wound.
The patient died of septic poisoning. Now many surgeons
might have said, ' I used the spray ; 1 used all precautions ;
my instruments were soaking ; my hands were purified ; ' for-
getting this one little incident. When the point was men-
tioned, however, the mistake was at once seen. People are too
apt to trust to the spray as sufficient, and to speak of aseptic or
Jjisterian surgery as treatment by the spray. This is a great
and often fatal mistake. Of all the precautions required by
Mr. Lister, that of purifying the air by means of a carbolic acid
spray is the least necessary, for there are but few septic particles
present in the atmosphere, and even though some of them fall
on to a wound they may be rendered inert by washing the
wound with carbolic lotion. It must always be remembered
that Mr. Lister carried out aseptic treatment for years with
great success without any spray ; and if at the present time he
were compelled for any reason to give up some one precaution, he
would at once throw aside the spray, as that one which is least
74 ASEPTIC SURGERY.
necessary, and which could be the most readily dispensed with.
At the same time, the spray is an immense convenience in many
cases, more especially in abscesses, empyemata, in stitching up
wounds, &c. ; and it saves the necessity of applying a great deal
of carbolic acid to wounds by irrigating them, with the con-
sequent irritation and risk of carbolic acid poisoning.
To return to the errors which may arise in this part of the
treatment. It may be that the spray is too near, and that thus
the cloud is so narrow that the surgeon is constantly getting
his hands or his instruments out of it, and forgetting to re-
purify them. There are other disadvantages when the spray is
too near. Thus it is very wetting, and the hands of the surgeon
and the wound are unnecessarily irritated by the carbolic
acid. If too near, the opaque spray also obscures the field of
vision. On the other hand, where the spray is visible, it may
be sufficiently trusted. Other sources of error are that instru-
ments may be used which have never been purified, which have
been only imperfectly purified, which have after their use lain
about outside the spray or on blankets, &c. ; or it may be that
the carbolic acid gets exhausted in the spray bottle, or that for
some other reason the spray does not act properly.
What is to be done should any of these accidents occur ?
Suppose that an impure instrument or finger be introduced into
the wound, that wound must be at once thoroughly washed
out with 1-40 carbolic lotion. This is a bad thing for the
wound, because it irritates it, and may prevent lijealing by first
intention ; or it may, by causing a much larger quantity of dis-
charge than usual, so saturate the gauze dressing as to render
it unable to prevent the spread of putrefaction inwards. There-
fore it is better to use the spray, and to take all the precautions
before mentioned. Should the spray stop, the wound must be
washed out just as in the former case, and then, till the spray
can be set agoing again, the wound is covered with a piece
of rag soaked in carbolic lotion.
This piece of rag, called the guard, ought to be always
present in the basin by the side of the surgeon, and when there
is any indication that the spray is failing, or should it be advis-
able to stop the spray for any reason, this is thrown over the
wound for the time being. Should any time elapse before the
METHOD OF TYING VESSELS. 75
spray is again ready for use, this guard must be repeatedly
moistened with carbolic acid lotion 1-40.
Where the wound is very large it may be protected during
the operation either by having two sprays, or by covering up the
part of the wound which is not being operated upon by a guard
(see Fig. 24).
The arteries are ligatured with catgut. This catgut is
generally employed of three different sizes. The largest is
used only for large vessels or for stitches; the medium for
medium-sized vessels, or for vessels in inflamed or dense tissues
where considerable force is required to constrict the vessel, or
for stitches ; the small or fine catgut is that ordinarily employed
^-^
Fig. 25a. — Method op tying vessels in dense tissues.
(After MacCormac.)
for the smaller vessels. The vessel having been securely tied,
the catgut is cut short and gives no more trouble. It is well
to tie all the visible bleeding points, because a little oozing of
blood may give trouble afterwards from tension. If the vessel
be situated in dense tissue, so that a ligature cannot be applied
around it, a needle carrying a double catgut thread should be
passed througli the tissue and tied on each side of the vessel
(see Figs. 25a and 2oh). The catgut should be taken direct
from the trough containing carbolic oil, and should not be
wetted in the lotion. Where the bleeding is from a tear in
a large vein, and where it would be dangerous to ligature the
76
ASEPTIC SURGERY
vessel, I have seen the following method adopted by Mr.
Lij^ter: — In removing some cancerous glands from the axilla,
a small vein was torn away from the axillary vein at their
junction, making practically a longitudinal rent in the axillary
vein. Taking a fine curved needle and the finest catgut, he
stitched up the rent by the glover's suture. The patient
recovered without the slightest bad symptom. There was no
pain in the wound, nor swelling of the arm, &c. In another
case, where the longitudinal sinus was injured in trephining
the skull, the w^ound was plugged with catgut, and the patient
recovered without any untoward symptom.
The drainage of an aseptic wound is the point next in im-
portance to keeping the wound aseptic. For if the blood and
serum which collect in the in-
terior of the wound within the
first twenty-four or forty- eight
hours do not get free exit, they
give rise to tension, and tension
gives rise to inflammation, and
the latter, if allowed to go on long
enough, to suppm'ation ; and
thus the rapid healing of the
TYING VESSELS IN DENSE TISSUES, wouud is prevented, though the
(From Esmarch.) paticut is uot as a rulc subjcctcd
to any danger to life. To avoid these consequences Mr. Lister
has paid very special attention to the drainage of wounds.
There are two main ways in which this may be done— drainage
through tubes, or drainage by capillarity. The former is the
most universally applicable and the most certainly successful.
Drainage by means of tubes is that first used by Mr. Lister,
and, as just stated, is the form of drainage which is most uni-
versally applicable. The tubes generally employed are the
india-rubber tubes introduced by Chassaignac, though of late
the kind of rubber has been altered, that now used being red
rubber, which contains no free sulphur. By the use of these
red rubber tubes disagreeable smells and blackening of the
X^rotective, which often occurred when the black tubes contain-
ing free sulphur were employed, are avoided. These tubes have
round holes cut in them at short intervals, the diameter of each
Fig. 25&. — Another method of
DRAINAGE-TUBES.
77
hole being about one-third of the circumference of the tube.
At the outer end the tubes are cut flush with the surface of
the skin — straight across if the tube goes directly downwards,
or with varying degrees of obliquity according to the direction
Fig. 26. -Ordinary oblique-ended drainage-tube ready for use.
which the tube takes (Fig. 26). The tube must not project be-
yond the surface, for if it does, its orifice gets compressed by the
dressing, and the exit of fluid is prevented. To keep the drain-
age tube from slipping in, two threads of carbolised silk are
Fig. 27.— Duainage-tubk with masses of gauze in the loops of
thread.
fastened into it at its orifice, and tied in a knot. This knot,
held between the dressing and the skin, retnins the tube in
])08ition. In souk; cases, however — as for cxiimple, in ompyeuia —
the tube niiglit sli]) in in s})ite of these thrends, and th(n-('f()re it
is well to fill u|» (he ]oo])S witli strips of gauze soaked in the
78
ASEPTIC SURGERY.
carbolic lotion (Fig. 27). These absolutely prevent the tubes
from slipping in. These tubes are always kept in a large vessel
containing 1-20 carbolic acid solution, and are thus always ready
for use. When a tube is altogether removed from a wound it
is not thrown away, but is washed and put into the bottle
with the other tubes, and used for another case. These tubes
vary in size according to the size of the wound and the amount
of discharge expected, and are arranged so as to drain the
parts of the wound which form cavities or from which the
greatest amount of discharge will come It is not necessary that
their orifices be dependent, though it is of course better that
they should be so. It is not essential, however, because the
fluid, as it forms, wells out, and, not being putrid, that w^hich
lies at the bottom of the drainage-tube does not cause irritation.
In cases where the most dependent opening would be near
sources of putrefaction, it is well to have the drainage-tube in
another part of the wound, even though it be not so de-
pendent. Thus in inguinal
hernia the tube would no
doubt be in the most depen-
dent part if its orifice were
close to the pubis, but as that
would be much too near
sources of putrefaction, such
as the vagina and penis, the
orifice of the tube ought to be
at the outer angle of the
wound (see Fig. 28). In a
large wound it is well to have
more than one tube; and it is
better to have two smallish
tubes in any case, rather than
HERNIA, STITCHED, SHOWING THE OHC large ouB, bccausc ou the
POSITION OF THE DRAINAGE-TUBE day after the operation one of
OUTER ANGLE OF THE ^|^ggg ^^j^^g ^^^ ^^ rCmOVCd
altogether ; whereas if a large
one were pulled out in order to insert a smaller, there would
be the gi-eatest difficulty in introducing either. No tube which
one wishes to put back again should be removed till the third
Fig. 28.— Incision for inguinal
AT THE
WOUND.
BRAIXAGE. 70
day, on account of the difficulty of returning it. By that time,
however, it Hes in a channel in the blood clot or Ijonph, and slips
back easily. Fig. 29 represents forceps introduced by Mr. Lister,
and called ' sinus forceps,' which are of the greatest service in
inserting drainage tubes. Generally on the third day half the
tube is cut off, and it is reduced in length at subsequent
dressings till it becomes no longer necessary. No exact rules
can be given for shortening or leaving out the tube. This must
simply be a matter of experience, guided by the amount of
discharge and the tendency to accumulation or otherwise.
Should tension occur, a larger and longer tube ought to be at
once introduced.
A point which has always seemed to me of great importance
in connection with the use of these tubes, and one which has
apparently been overlooked, is the following. A tube is taken
Fig. 29.— Sikus forceps.
out of carbolic lotion at some distance from the spray, is
earned through the air, and then directly introduced into the
wound. I can hardly believe that when a large tube is taken
out of the lotion there would be sufficient vapour of carbolic
aoid in it to destroy any septic dust which might get into its
interior, for a considerable mass of air must take the place of
the fluid, and this amount of hospital air may often, as I have
found by experiment, contain causes of putrefaction. Of course
when passing through the spray this air may be displaced or
purified, and also when introduced into the wound a consider-
able amount of it would be forced out ; while at the same time
there is a good deal of carbolic acid present, and purification in
one way or another would probably occur. And further the
purifying power of healthy living tissues, which will be after-
wards demonstrated, must be taken into account. But in
the case of a cavity, pm'ification in any of these ways may
80 ASEPTIC SURGERY.
not happen, and putrefaction may result. In a ease of incision
into the knee-joint, which will be afterwards alluded to, in
which fermentation and inflammation occurred, this seemed
to me the most probable explanation. My suggestion there-
fore is always to take the tubes out of the lotion in the spray,
and then the air which enters them will be air previously acted
on by the spray.
Drainage by capillarity was introduced by Mr. John Chiene,
who was also the first to enunciate the principle of absorbable
drains. For this purpose he uses catgut, and generally the
Fig. 30.— Catgut drain ready foe insertion.
finest threads. A skein of catgut, containing say twenty threads,
is tied at its middle by a single thread of the same gut. One
end of this thread is passed through a needle (Fig. 30), and by
means of this the centre of the skein is stitched to the deepest
part of the wound (Fig. 31). The skein is now broken up into
bundles of five or six threads each. One bundle comes out
at each angle of the incision, and the other bundles at inter-
vals between the stitches (Fig. 32). More than one skein
may be required in a large wound. This catgut becomes
absorbed, and never requires to be removed. In five or six
days the ends which hang out' drop off, and little granulating
sores are formed which heal in a few days. In this method the
serum escapes by capillarity, and by distributing the threads
DEAINAGE BY CAPILLARITY. 81
over various parts of the wound the true principle of drainage
is carried out ; for, as pointed out by Mr. Chiene, in draining
a field one does not have one large drain going from one end
of the field to another ; on the contrary, the field is traversed
by numerous small drains. And so in Chiene's method of
draining v^rounds we have a number of small drains traversing
the wound in several directions. In this method there is no
trouble about pulling out the drain, and no necessity for
changing the dressing simply to remove a tube ; the drain
disappears of itself. It is well to leave the ends of the catgut
outside the wound as long as possible, so as to get a siphon
action, and care must be taken not to break up the bunches
of catgut outside the wound, for the capillary action occurs
in the intervals between the threads when they are closely
ajjposed.
The objections urged against this method are, firstly, that
in lai'ge wounds it is not sufficient, and that the catgut becomes
a pulpy mass, and when in large quantity takes a long time to
organise. Not only may it be insufficient at first, but it may
become absorbed too soon — before, indeed, a drain of some
kind can be dispensed with.
Now these objections rest in great part on the fact that
the drain is often improperly employed. If, for instance, it be
not stitched to the deepest part of the wound, the catgut may
slip and the deeper parts may not be drained ; and again, if a
large bundle of it be used, coming out at one part of the wound
only, it does become a pulpy mass, and takes a long time to
organise. But this is not the method recommended by Mr.
Chiene, for he says that only five or six threads ought to be
brought out at each place. There is, however, no doubt that
in some cases it is absorbed too quickly, and this was the real
objection to the use of this method when we had only the
catgut prepared by the old method, though even with it, if the
gut was well prepared and old, the drainage was often very
satisfactory. This difficulty will probably be overcome by the
use of the chromic catgut recently introduced ; the only fear,
indeed, will now be that the drain may last too long. Mr.
Lister, however, thinks that if only the finest gut be used,
according to Mr. Chiene's directions, the probability is that it
G
82 ASEPTIC SURGERY.
will be absorbed with sufficient rapidity. Of course, if neces-
sary, the ends of the drain can be cut off, when it has served
its purpose, below the level of the skin, and then, even though
the internal part be not all absorbed, the wound can heal
completely.
Catgut can only drain fluids such as blood or serum ; it
cannot drain pus. It is, however, unsuitable in cases of chronic
abscess, where we have only a serous discharge, because the
catgut is absorbed long before a drain can be dispensed with.
Fig. ni.— Operation for stretching the sciatic nerve.
Catfrut drain stitolicd to the deepest part of the wound, beneath the gluteus maximus, and
lirukon up into four separate bunclics.
If the wound is very large it is well to introduce tubes as
well as catgut drains at first. The tubes may be removed in
twenty-four hours.
Instead of catgut, horse-hair has been a good deal used.
This is simply laid into the wound in the situation where it
seems most required. It is diminished by degrees, threads
being taken out at various intervals of time. It has an advan-
tage over catgut in draining joints, for no part of the drain
DRAINAGE BY CATGUT AND HORSEHAIR.
83
remains in the interior of the joint, while portions of catgut do.
Further, it is not absorbable.
But it has the same disadvantages as the drainage tubes,
and it is not readily retained in the deeper parts of the wound.
It is preferred by Mr. Lister to the catgut, but there can be no
doubt that the catgut, when used strictly according to Mr.
Chiene's directions, and of good quality, is a very efficient
method of drainas^e.
It is easy to re-introduce a horse-hair drain if necessary by
proceeding in the following manner : — A sufficient quantity
Fig. 32.— The same wound stitched.
The h'jnclips of rntpiit cnminp out at intprvals between t)ie stitclies. (Tlie woiintl lias teen
exapperated, and the thnails of ratjzut separated, in order to sliow the nietliod more clearly.
'I'lie thnads of catpiit onpht to lie in close apiiositioii, for it is tin: iiitervnls between the
threads which act as raiiillary drains'.
being taken, the bundle is bent at its middle over a probe, and
tied close to the probe by carbolised silk (Fig. 33). In this
w^ay, the ])robe being withdrawn, a blunt compact end is oblained,
which may be introduced into the wound with ease.
Of lute the princi])le of absorbable drains has been applied
by Dr. Neuber of Kiel ' in his absorl)al)le drainag(! tubes.
' Ein AnihepHgchcr Daucm-rhand narh fir'dndlichrr Jilutstillnii;/. Von
LangenhccJt'x Archiv, Bd. xxiv. Heft. 2.
a 9.
84 ASEPTIC SURGERY.
These are tubes drilled in long bones, and then decalcified and
carbolised. Holes are afterwards cut in the sides, and they are
used like ordinary india-rubber tubes. These tubes are said to
answer very well, though they are sometimes absorbed too soon,
and sometimes last too long. They sometimes get soft and
collapse about the third or fourth day, and thus, though not
absorbed, become useless as a drain.
Dr. INIacEwen ^ has lately somewhat modified Neuber's tubes.
He uses chicken-bones, which are already hollow, and decalcifies
them. ' The method of preparation is as folloAvs : — The tibia?
and femora are scraped and steeped in hydrochloric acid and
water (1 to 5) until they are soft. Their articular extremities
are then snipped off with a pair of scissors ; the cndosteum is
Fig. 33. — Method of preparing a horse-hair drain for
re-introduction.
raised at one end and pushed through to the other extremity,
along with its contents. They are then re-introduced into a
fresh solution of the same strength until they are rendered a
little more pliable and softer than Avhat is ultimately required
(as they afterwards harden a little by steeping in the carbolised
solution). When thus prepared they are placed in a solution of
carbolic acid in glycerine 1-10. They may be used at the end
of a fortnight from the time of introduction into the glycerine
solution. Holes may be drilled in them with a punch, or clipped
out with scissors.' These tubes are threaded with horse-hair
before being introduced into the tissues. This hair helps to
maintain the calibre of the tube during the first few days, and
also itself acts by capillarity.
' British Medical Journal, Feb. 5, 1881.
BUTTON STITCHES.
85
The average duration of j\IacE\ven's tubes in the tissues
was something over eight days. If, however, a tube is likely to
be required for a longer time, it can be obtained by steeping
the decalcified tubes in a chromicised instead of a carbolised
solution. These resist the action of the tissues for two or three
weeks.
The accurate stitching of the edges of the wound is another
feature in aseptic surgery. In operating aseptically the same
care need not be taken to remove as little skin as possible as
is necessary in wounds treated by other methods where swelling
and inflammation of the edges are expected. One may take
away a wide sweep of skin, such as would seem to render
hopeless any attempt to bring the edges of the wound into
apposition ; and yet if the edges can only be apposed, and if
A c
Fig. 34. — Lead buttons for deep stitches.
A, The present form, describerl in tlie text. B, Form of button deviscrl by Dr. Ogilvie Will (seen
in section). C, The old form, where the wire was fastened by passing it beneatli the button.
the wound remains aseptic, union by first intention may be
expected along the whole line.
Button stitches are employed to relax the edges of the
wound, and thus to leave the cutaneous margins free from the
irritation which must occur if they are tightly drawn together.
These consist of flat pieces of lead cut of an oval form and of
various sizes, perforated in the centre by a hole through which
silver wire is passed, and provided Avith two lateral wings round
which the wire is twisted (Fig. 34). (There are various forms
of button suture, but all act on the same principle.) These are
a[)})lied some distance on each side of the edge of the wound,
and connected by strong silver wire drawn tight enough to
permit the edges of the wound to come pretty easily together.
The number used varies according to the amount of tension.
8(>
ASEPTIC SURGERY.
In order to bring the edges of the wound into actual contact,
two sets of stitches are employed : silver wire stitches, which
take a good hold of the tissues and are placed at regular inter-
vals, termed stitches of relaxation ; and in the intervals between
these, in order to have the cutaneous margins accurately applied
to each other, numerous stitches of coaptation, consisting of
carbolised silk, horse-hair, or catgut are inserted (Fig. 35).
The speedy healing which occurs when the edges of the wound
are accurately brought in contact, while they are at the same
time, by the button stitches and the stitches of relaxation,
Fig. 35. — Wound after removal oi'^ mamma and axillary glands,
STITCHED.
To show tlie tliree kinds of stitches. Tlip button .stitchrs will lie at onee recognised ; the tliick
stitches, of which three arc represented, are the stitches of relaxation ; and the remainder
are tlie stitches of coaptation.
freed from any tension, rewards the surgeon for the time
spent in inserting a large number of these stitches of coapta-
tion.
In taking out these stitches it is best to follow a reverse
order to that of insertion. The first to be removed are the
stitches of coaptation, while the stitches of relaxation are pro-
bably cut on the same day. Do not be in a hurry to remove
the stitches where there was much tension in bringing the
edges of the wound together. A week or ten days is time
enough.
Should the wound gape, strapping may be employed, even
under an antiseptic dressing. To render the stra])ping aseptic,
it is immersed in warm carbolic lotion (one part of 1-20 and an
equal part of boiling water) before being applied. This both
BEESSINGS. 87
renders it aseptic and also takes the place of the hot- water can
for heating the strapping.
Having proceeded thus far in the aseptic operation — having
tied the vessels, aiTanged the drainage, and brought the edges
of the skin well together— we must now apply a dressing which
shall prevent the occurrence of putrefaction till the case is
again seen.
In applying a dressing we must in the first place be careful
to make it as little irritating as possible to the young epithelium
along the Hne of incision. The dressing employed is the car-
bolic gauze ; and, to prevent the irritation of the healing edge
of the wound by the carbolic acid, a piece of protective is inter-
posed between the gauze and the wound. This protective is
cut a little larger than the wound, and it is well to cover the
buttons with a little bit also, in order to prevent the threads
of the gauze from becoming entangled in them. This protective
need not extend over the orifice of the drainage tube, as its
essential object is to protect the healing part from the irritation
of the carbolic acid. The protective is also of use in preventing
the dressing from sticking to the Avound, and in preventing the
formation of scabs, and the consequent possible retention of
the discharge.
An eiTor which is frequently made is to put on too large a
piece of protective. There is nothing antiseptic in its substance,
and it protects the discharge beneath it from the action of the
carbolic acid. Therefore if at any part it projects beyond or comes
close to the edge of the dressing, it allows the causes of putre-
faction to spread inwards beneath it, and prevents the carbolic
acid from acting on this putrefying discharge. It is therefore
a very good rule, having covered the woimd with sufficient pro-
tective, to look on this protective as a wound, and to be as careful
in having the gauze dressing overlap it in all du-ections as if it
itself were the wounded surface. Where there is very little
space for overlapping, as in inguinal hernia, no protective ought
to be applied. It is better to have somewhat slower healing
than to have putrefaction spre-ad into the wound. As men-
tioned before, this protective is di))i)ed in carbolic lotion 1-40
befoi'e being applied.
Outside the protective a piece of gauze wet in the carbolic
88 ASEPTIC SUliGEliT.
lotion 1—40 is applied so as to overlap the protective in all
directions. The reason for this is that dry gauze is apt to
receive dust on its surface before being used, while at the
ordinary temperature of the atmosphere but little carbolic acid
is given off from the gauze, certainly not enough to destroy
immediately the activity of the septic particles in the dust.
But if the piece of gauze applied next to the protective be
moistened in the 1— iO solution, this dust is at once deprived
of septic energy, and we apply over the wound a layer of pure
and powerfully antiseptic material.
Fig. 36.— Excision of the hip-joint.
Wound stitclied ; ])rotective anil deep di-essing applied.
The piece of wet gauze and the protective go by the name
of the deep dressing. This deep dressing may in some cases,
and more especially where catgut stitches and catgut drains are
used, be left for several days undisturbed. In this way the
wound is not irritated by the application of carbolic acid to it
every time the dressing is changed. If the deep dressing be
thus left on, it must be remembered that the deep piece of
gauze loses all its carbolic acid very soon, and that therefore
it must be treated as a wound — ^.e., in renewing the dressing
this deep part must be overlapped in all directions by a
piece of wet gauze, and that again by a dressing of suitable
size.
DEEP DRESSING. ^9
In some cases it may be desirable to fix down the deep
dressing with a piece of gauze bandage. If it be intended to
leave on this deep dressing for some time it is well, before
applying it, to rub the neighbourhood of the wound with the
salicylic cream mentioned before. It sometimes happens that
when a dressing is left on for many days together, the discharge
becomes somewhat irritating, and the skin around the wound
becomes excoriated. This is generally entirely prevented by
the use of salicylic cream.
Having arranged the deep dressing in a suitable manner,
any hollows which exist in the neighbourhood of the wound
are filled up with carbolic gauze, and special masses of this
material are placed where the greatest amount of discharge is
expected. Outside this a large gauze dressing, made as before
described, is applied. The size of this dressing varies accord-
ing to the amount of discharge expected, but in all cases it must
extend well beyond the deep dressing in all directions. Some
special examples will be mentioned presently.
This dressing is fixed on with a suitable bandage. The gauze
bandage is preferable to an ordinary bandage under certain
circumstances. It is especially convenient in bandaging a
stump next the skin to prevent retraction of the flaps, and also
for fixing down the deep dressing. It also increases the amount
of antiseptic material outside the macintosh if there happens
to be a hole in it. But for ordinary use in fixing on dressings
very light and cheap bandages may be made from the ordinary
thin muslin which is used as a guard. They do not stick to
the skin as the gauze bandage is apt to do.
The dressing is pinned round its edge to the bandage.
Care must be taken not to put pins through the macintosh at
any part except at its edge. Pinholes through the centre of
the macintosh simply defeat its object by permitting the
discharge to come directly through the dressing. The object
of the macintosh is to make the discharge travel through a
large extent of the gauze, and thus the same result is obtained
as if a mass of gauze were applied over the wound, of the same
thickness as the distance from the centre of the macintosh to
its edge. If therefore there be a pinhole near the centre of
the macintosh, the object of the latter is seriously interfered
90
ASEPTIC SURGERY
with. Accordingly, it is always the duty of the i)ersoii who
makes the dressings to examine the macintosh with the view
of detecting any holes in it.
If the dressing is to be used as soon as it is made up, it is
well to sponge the surface of the macintosh with 1-20 carbolic
lotion before inserting it. The same piece of macintosh may
be used for a whole case, or for more than one — so long, in fact,
as it does not become worn into holes. Two pieces of macin-
tosh are generally provided for each case, and a dressing is
always made immediately after the case has been dressed, and
is ready for application at any time.
Fio. 37.— Dressing in a case of psoas abscess opened above
Poupakt's ligament.
To show tlie an-angement of tlie elastic bandage along the margins of the dressing.
It might happen that, in the movements of the patient, the
edge of the dressing might become separated from the skin,
and air pass into the space thus formed. To prevent this, the
German surgeons as a rule pack in salicylic jute or wool be-
neath the edge of the dressing. This may serve the purpose,
but it is by no means safe. Mr. Lister some time ago intro-
duced the use of elastic webbing, which is of various breadths.
It is better not to be too broad. It is put moderately on the
stretch, and surrounds the edge of the dressing. Its general
arrangement varies of course with the situation. It is not much
used on the extremities, because the ann or leg is generally so
CHANGING OF THE DRESSING. 91
fixed by means of splints that there is no chance of separa-
tion of the dressing.
The operation and first dressing ha\iug now been com-
pleted, the question arises when the dressing should be changed.
It is only extremely rarely that it is necessary to change it the
same evening. The only cases in which this is usually done
are large empyemata or very large abscesses, and cases of am-
putation at the hip-joint, where the discharge of bloodly serum
is profuse, and there is but little space for overlapping of the
dressing.
As a rule, the dressing ought to be changed entirely on the
following day, the deep part as well as the superficial. It is
well to change the deep dressing in order to see that none of
the stitches are too tight, and that the drains are acting pro-
perly. After the first day the deep dressing need not be
touched, unless the patient is complaining of uneasiness, or
unless the sm-geon wishes to see the wound for the purpose of
removing stitches or drain. If it is not necessary to disturb it,
it may, especially where there is an organising blood-clot, be
better not to do so, for that would only be to expose the wound
unnecessarily to the irritation of the carbolic acid. If the deep
dressing is not changed, great care must be taken to have an
efficient spray playing over the part.
In changing the dressing the spray is used, and also 1-40
carbolic lotion, in which a piece of loose gauze and protective
are put before the dressing is begun. The elastic bandage
is first removed, and then the patient or an assistant places
his hand over the centre of the dressing while the bandage
is being cut, so as to prevent the dressing being lifted up
and air pumj)ed in. Then the surgeon, having purified his
fingei's, and having turned on the spray, lifts the edge of the
dressing carefully, taking care that the spray passes into the
angle between the dressing and the skin (see Fig. 38). Having
removed the superficial dressing, he again dips his fingers,
and then removes the deeper parts and exposes the wound.
If nothing is wrong, he immediately applies fresh protective
and wet gauze, and then washes the parts round about, as far
as the discharge has extended, with 1-40 carbolic lotion. The
92
ASEPTIC SURGERY
edge of the wound is not washed or exposed to the action of
the spray longer than is absolutely necessary. It is well to
apply the deep dressing at once, for in washing the surround-
ing parts, one is apt to give the wound a final touch with the
rag. Now this rag may contain some gross particles of putrid
material (such as a crust of discharge from the exterior of the
dressing, faeces, &c.), and thus putrefaction would be com-
municated to the wound. There is no necessity for cleansing
the edges of the wound. Dirt, so long as it is clean, i.e., so
long as it does not contain causes of putrefaction, does no
harm ; indeed, it rather aids the action of the protective ; while
Fig. 38.— Method of changing a psoas abscess dressing.
A Hand of patient holding down tlie dressing over the wound. BB, Hands of surgeon lifting
' the lower^«l?e of th^ dressing (C). D, The spray machine so placed that the spray passes m
beneath the dressing as it is lifted.
to rub it away is to irritate and injure the healing edge— to
produce a state of unrest. A fresh dressing is applied as before
described.
Where there are two wounds in different situations, so
placed that the spray cannot command both, each must be
dressed separately, care being taken not to uncover the one
till the other is at any rate protected by a deep dressing. The
patient or assistant must keep his hand on the dressing over
the one wound, while the other wound is being attended to.
The next dressing takes place on the following day at visit,
RULES FOR CHANGING THE DRESSINGS. 98
if there is any discharge at the edge of the dressing or if the
wound feels uneasy. If there is no discharge on the drawsheet
and if the wound is free from pain, the dressing is not changed ;
and even though discharge should appear a few hours later,
the dressing is not changed till next day at visit hour. The
rule for changing the dressings is therefore : Change if
discharge is through at the visit hour, or if there be any other
reason for it ; if not, leave the dressing till next day at visit,
and then follow the same rule.
Never leave a dressing unchanged longer than a week. By
that time most of the carbolic acid ha5 passed off by evapora-
tion ; and therefore, if the discharge once came to the edge,
putrefaction could spread inwards with great rapidity. And it
would not be necessary for the discharge to appear at the edge
in order to have putrefaction of the wound, for the sweat
collecting beneath the dressing permits the multiplication of
septic particles in it, and thus they may reach the wound.
Where a dressing is to be left on for a week, it is well to use
the salicylic cream in the way before described.
Such is the general method of using carbolic dressings ;
special modifications will be noticed presently. Let me pass
on in the meantime to the general points as to boracic
dressings.
Let us sup})Ose that a patient is admitted with a foul ulcer
of the leg : how is he to be treated ? If he were to be ti'eated
with carbolic dressings, the ulcer would very probably remain
foul, or even though it ultimately became free from odour, it
would heal excessively slowly. Hence, Mr. leister first piuifies
the sore, and then dresses it with boracic acid.
To purify the sore, chloride of zinc, 40 grs. to the ounce
of water, may be used. This is applied tlioroughly to the
whole surface of the sore, and at the same time the surrounding
skin is well purified by thoroughly washing it with 1-20 carbolic
lolion, whieli is em])loyed on account of its special power of
jx'uet rating the epidermis. When iliis lias been done, a. jiiece
of protective, dii)ped in boracic lotion and slightly larger than
the sore, is applied over it, and outside tliis is placed one or
two layers of moist or dry (it docs not much matter which)
94 ASEPTIC SURGERY.
boracic lint, of sufficient size to cover the protective well in
all directions. There is the same objection here to allowing
the protective to project beyond the edge of the dressing
as in the case of the carbolic dressings. Lately, instead of
applying the chloride of zinc solution, which causes consider-
able uneasiness, iodoform has been yjowdered over th,e whole
surface of the ulcer, and it has been equally successful. The
chloride of zinc or the iodoform need only be applied once ;
but should putrefaction not be eradicated, the application is
repeated.
This dressing is changed next day, but aftei-wards, as a
rule, if only requires to be changed every two or three days, or
indeed at longer intervals, provided that there is not much
discharge. That is to say, as there is a very large store of the
antiseptic in the lint, and as it is but slightly soluble at the
temperature of the human body, the discharge may go through
the dressing many times without washing out all the antiseptic.
At the same time it is found as a general rule that the wound
heals most rapidly when the dressing is changed once in three
or four days.
At the changing of the dressing no spray is required. The
bandage (which may be a common cotton bandage, if preferred)
having been removed, the dressing is taken off' and the wound
well washed with boracic lotion. Any septic dust which falls
on the wound during its exposure is destroyed by giving the
wound a final wash with the lotion before applying a fresh piece
of protective and boracic lint.
This boracic dressing is not used for wounds which are not
quite superficial, because the acid is not volatile, and because
it is but a feeble antiseptic ; but when once a wound has be-
come quite superficial, it will heal more quickly if treated with
boracic dressing.
In some cases, more especially where the sore is septic, or
where the patient dresses it himself, boracic ointment is prefer-
. able to protective, and where the sore is healing, the half-
strength ointment is the best. Outside the ointment a piece
of boracic lint is applied as usual. Of late, salicylic ointment
has been used, and found to answer, as a rule, better than the
boracic. It is less irritating, and permits healing more readily.
B-ORACIC DRESSINGS. 95
A eucalyptus ointment has been employed quite recently, and
has given excellent results.
VV^hen the effects of a poultice are wanted along with an
antiseptic effect, the boracic lint is applied like water dressing.
A suitable piece of the lint moistened in boracic lotion is ap-
plied, and outside this a larger piece of macintosh or gutta-
percha, overlapping the lint in all directions.
96 ASEPTIC SURGERY.
CHAPTER V.
ASEPTIC SURGERY_(co«^f««frt?).
Special dressings : Head dressi/if/s : Ned; dressings : Breast dressiiiffs — Abscess
of vKimina — Excision of mamma alone — Excision of inamnia and axillary
qlands : Axillary dressings : Dressings on the limbs : Dressings for psoas
abscess : Lumbar abscess : Hijf-joint abscess : Dressings in cases of hernia
and operations on the scrotum: Excisions of joints. Aseptic treatment of
abscesses. Chief xjoints to be considered in opening abscesses — Mi-thod of
openi7ig abscesses — Drainage of abscesses — After-treatment of abscesses —
Empyema — Perinealand anal abscesses. Treatment of wounds produced acci-
dentally : Problem to be solved — Purification of wound — Further treatment
of the wound. Special wounds : Compound fractures : Wounds invoicing
tendons, nerves, ^'c. : Wounds of joints : Compound fractures of the skull :
Penetrating wounds of the thorax: Wounds of the abdomen. Putrid sinuses
■ and wounds. Treatment of burns. Treatment of gangrene. Treatment
of na3vi and varicose veins.
I SHALL now describe the special methods of dressing and other
precautions required in different sitiuitions.
In operating on the scalp the hair must be shaved for some
distance around the wound, and the hair beyond ought to be
soaked with carbolic lotion 1-20. If the incision be in the
centre of the scalp, or, in other words, if there be a circle of
hair all round it, it is better not to use j^rotective at all. The
dressing in such a wound is fixed by the ordinary capelline
bandage. Where the wound is more or less to one side, the
dressing must extend downwards on the neck, and it is then
well to have a narrow elastic bandage along the edges, more
especially around the neck. In the neighbourhood of the ears,
the various cavities in the ear, and the space behind it, must
be filled up with gauze.
Nech dressings have nothing very unusual about them. The
dressing must be ftistened round the neck. It must be pre-
vented from slipping down by a turn passing above the ears
BREAfiT DRESSISGS.
and around the forehead, and also by two vertical turns over
the head, one transverse and the other longitudinal, these
various tiurns being pinned together
where they cross. To prevent the dress-
ing from slipping up, turns are passed
under the axilla. A narrow elastic band-
age must be applied round the edge of
the dressing in this situation, for the
movements of the head are extremely a})t
to cause an interval between the skin
and the dressing (Figs. 39 and 40).
Breast dressings are very important ;
they are arranged in three different ways
according to the size and extent of the
wound.
No. 1. — Where an abscess of the
mamma is opened, or where some small
incision, not interfering with the form of
the organ, is made, the dressing consists
of an ordinary gauze dressing covering Fig. 3"j.
the whole mamma, some loose gauze This figme illustrates the genr.
being packed in in front and behind. '"' ^'''"■^'^■"^"^ °f '»■•«-
This is fixed by turns of bandage passing
round the body alternately above and
below the organ, with straps over the
shoulder. The arm is placed in a sling.
by elastic bandage (Fig. 41).
No. 2. — Where the mamma has been removed and the dis-
charge has become much diminished in amount, there mav
remain enough of room between the wound and the axilla for
overlapping of the dressing. In order to fix the dressing and
keep it well up in the armpit, it is split vertically at the
axilla, folded over, and pinned on the top of tlie shoulder. It
is then bandaged securely, and an elastic bandage a])i)lir(l
around the edges (Fig. 42).
No. 3. — Where the mamma and axillary glands have been
removed, or for the first few days after excision of the mamma
alone, this arrangement is not enough, for it does not leave
sufficient room for overlajipiiig. The arm must therefore be
nigs on the neck. The ar-
rangement shown liero
would do for any operation
about the region of the stcv-
nouia.stoid behind or below
the ear.
The edges are fixed
98
ASEPTIC SURGERY.
included in the dressing. This is accomplished most con-
veniently in the following manner : — A large dressing is applied
FICt. 40. — To SHOW THE ARRANGEMENT OF THE TURNS OP BANDAGE ON
THE HEAD SEEN FROM ABOVE.
posteriorly, reaching behind as far back as the middle line,
and folding over the arm so as to touch the thorax in front,
Fig. 41.— Dressing applied in a
case of abscess of the mam-
MA (BREAST DRESSING NO. 1).
The position of tlip drainage tube is indicated
by dotted lines.
Fig. 42.— ]5reast dressing-
no. 2.
the arm being applied to the side. This dressing must be
broader than the length of the upper arm from the top of
BREAST DRESSINGS.
99
the shoulder to the tip t)f the elbow, the overlapping parts
being caught by the turns of bandage passing over the
shoulder and round the body respectively. To prevent the
internal condyle from suffering from the pressure, a large
mass of gauze is applied behind the arm, extending downwards
almost to the condyloid region, but not reaching quite so far.
A mass of gauze is packed in between the arm and the side,
and in front filling up the angle between the arm and the
thorax (Fig. 43). A smaller anterior dressing is then applied,
narrower than the posterior, reaching as far forwards as the
middle line or beyond it, and outwards to the upper arm, the
edge of the anterior dressing passing beneath the edge of the
Fig. 43.— Case op excision of the mamma.
Back dressing lying ready for application ; sliowing also the deep di-cssiug and padding in
the axilla and beljind the arm.
])Osterior. Thus the side of the patient is completely encased
in a gauze dressing. This is very easily bandaged on. One
turn of bandage passes round tlie body outside the arm (Fig.
44, 1); the second also passes round the body, but below the
elbow (2), thus catching the portion of the dressing overhang-
ing the elbow and also the lower edge of the front dressing ;
the next passes roimd the body and over the top of the
shoulder on the side operated on, thus catching tlie portion
of the dressing projecting above the shoulder (3) ; tlu; bandao-c
then passes down beliind but parallel to tlie arm, turns round
below the elbow, runs obliquely upwards in front to the top of
100
ASEPTIC SUR(rERY.
the opposite shoulder (4), then obliquely back again behind the
body (thus fixing the upper angles of the dressing in front
and behind) to the middle of the arm, over which it passes
obliquely downwards (5), to go under the wrist and end at the
top of the shoulder (6) — in this way completing the fixing of
the dressing to the arm, and at the same time acting as a sling
for the hand. A bandage six yards long generally does this
exactly.
Pins are now inserted at all the necessary points, more es-
pecially where the bandage passes over the shoulder and under
the elbow. The arm and dressing are then fixed seciu'ely to
the side by a binder of calico, broader than the length of the
Ki«. 44— Dressings applfeu aftek excision ov mamma and axillary
GLANDS, TO SHOW THE ARRANGEMENT OF THE DRESSINGS AND BANDAGES.
The turns of bandage are numbered, and arrows are placed on them to show the direction iu
which they run.
upper arm, passing round the body, below the axilla of the
other side, and pursed up and pinned above the shoulder, and
below the elbow of the included arm. Thus perfect rest is
procured, and no elastic bandage is required.
When the axillary incision is soundly cicatrised, and the
discharge has become small in amount, the axillary dressing or
the breast dressing No. 2 may be applied, the arm being
simply supported in a sling.
An axillary dressing must be ap[)lied partly to the chest
and partly to the upper arm, and made to fold over the top of
the shoulder. It requires an elastic bandage (P'ig. 46).
Elastic bandage is not as a rule required for dressings on
DRESSING Foil PSOAS ABSCESS.
101
the extremities, because the limb operated on is generally
placed on a splint for a few days, in order to procure absolute
rest till healing by first intention is complete. Thus the
movements which it is the function of the elastic band to
neutralise are avoided, and the constriction of the elastic is
also avoided. With regard to this constriction, however, the
elastic need never be applied so tight as to produce cedema ;
indeed, I have more than once seen oedema which was present
before an operation subside afterwards, even although an elastic
bandage was used. Where the patient is allowed to move the
extremity — as, for instance, when he is allowed to walk after a
small operation on the lower extremity — an elastic bandage is
Fir. 4.").— Bindee applied outside the dressing represented ix
FiG. 44, so AS TO keep the parts and dressing at rest.
absolutely necessary. In the case of the lower extremity, the
padding at the upper part of the splint should be covered with
macintosh, and the foot of the bed should be supported on
blocks. In this way all the discharge flows upwards, and as it
cannot soak into the padding of the splint, it is shed on the
draw-sheet soon after it has reached the edge of tlie dressing,
and thus one can ascertain accurately whetlier or not it is
necessary to change the dressings.
The dressing required for psoas abscess opened abo\e Pou-
part's ligament is one of the most important dressings, as well
as one of the simplest illustrations of the method of applying
the elastic bandage. I may say here with regard to this method
of opening psoas abscess :>bo\(' P()U))!irt's lignmcnt that there
102 ASEPTIC SURGERY.
are two reasons for choosing, this situation. In the first place,
the old rule that these abscesses must not be opened early is
now done away with, and under truly aseptic treatment, as
soon as fluctuation is detected, an operation is performed of a
similar nature to that for tying the external iliac artery, and
the abscess is opened after a careful dissection. The sooner the
abscess is opened the better, for the abscess cavity is thus
smaller than if the surgeon waits till the pus has burrowed its
way into the thigh ; and, further, so long as the pus is there
it irritates by its tension, and thus keeps up the chronic in-
FiG. 46. — Dressing in cases ov operation on the axilla alone.
In t)iis case an abscess has boen opened and tlie position of tlie draina.s;e tube is Indicated by
dotted lines. TLe ed!,'e of the dressing lias also been dotted in.
flammation in the si)ine. This, then, is one reason why the
opening leading into these abscesses is generally above Pou-
part's ligament. Another is, that even supposing the abscess
to be pointing in the thigh, it ought to be opened as far as
possible from sources of putrefaction, and the most convenient
place in this resj)ect, as well as the best for the attachment of
a dressing, is the neighbourhood of the anterior superior spine.
I shall hereafter discuss the reasons why it is thought best by
some surgeons, more especially by Mr. Chiene, to try to get
DRESSINGS FOll PSOAS AND LUMBAR ABSCESSES. 10.3
at these abscesses from behind either by perforating the ala of
the innominate bone or by getting at the pus above the crest
of the ilium. Such a method has advantages both by pro-
viding a dependent opening, and also by leaving a shorter
channel between the seat of the disease and the cutaneous
siu'face.
The dressing applied when the opening is in the neighbour-
hood of the anterior superior spine extends from the middle line
in front to the middle line behind. It reaches as high up as the
lower border of the ribs and as low as about three inches
below Pou})art's ligament. Special masses of gauze are placed
^ 1 iliVildlH''/
Fig. 47.~Dres3ing in a case of psoas abscess opened above
Poupart's ligament, seen from the front.
T]ie position of the drainage tube is indicated by dotted lines.
in the neighbourhood of the pubis, which is also shaved on
that side. The dressing is fastened on by a spica bandage with
circular turns around the thigh and abdomen. The elastic
bandage is applied accurately to the edge. It begins, say,
at the upper and anterior angle of the dressing, runs vertically
downwards along the anterior edge ; then, passing back round
the inner side of the thigh, it encircles the thigh, thus fixing
the lower border ; then it runs vertically upwards behind till it
reaches the upper posterior angle ; then, being held there, it is
carried round the abdomen. The two ends of the two vertical
pieces are fastened to the circular ])iece by pins, and pins are
also applied at all the angles and along the edge where neces-
104
ASEPTIC SURGERY
sary. In some deformed persons shoulder straps are necessary
to prevent the dressing from slipping down (Figs. 47 and 48).
Fro. 48. — r^iOAS abscess dre^sixo (Fig. 47), seex from behind.
In Inmhar abscess straps must pass over the shoulders to
prevent the dressing from slipping down, and between the
thighs to prevent it from slipping up (Fig. 49).
Vui. 49.— Dressing ix a case of lumbar abscess, seen from behind.
Tlie position of tlip rlrainage tube is indicated by dotted lines : the vertical dotted lines at the
niiildle of the back indicate the edge of the dressing.
In abscess of the hip-joint the arrangement of the dressings
is much the same as in psoas abscesses, except that they pass
lower down and not quite so high up. As a long splint is
I)Iii:SSINGS FOE HERNIA, ETC.
]05
generally in use, an elastic bandage is unnecessary, unless in
children (Fig. 50).
Where abscesses are opened near the top of the thigh on
the inner side, and are thus pretty near sources of putrefaction,
large masses of gauze must be applied between the orifice and
the perineum, and an elastic bandage carefully fastened along
the upper edge.
In operations for hernia^ varicocele, and on the scrotum,
in the male, there is one form of dressing which is generally
applicable. In the first place, no protective is used, on account
of the immediate vicinity of sources of putrefaction, as has been
previously explained. The gauze applied to the wound, instead
Fir. 50.— Dressing in a cask op hip-joint abscess, with elastic
APPLIED.
The dotted part sliows tlie position of tlie wound.
of being merely wet with carbolic lotion, is steeped in 1-5 or
in 1-10 solution of carbolic acid in glycerine, and this is
wrapped around the penis and over the scrotum. This gauze
sticks to the skin and does not become detached with the
movements of the body, while it is more powerfully antiseptic
than the ordinary carbolic gauze. Then a mass of gauze is
rolled into a ball, and this is suspended in the centre of a long
strip of gauze. The ball is i)laced in the jjerineum behind
the scrotum, and the strip of gauze passes u}) in each groin.
This strip retains the pad in position (Fig. 51). The pad
serves the double purpose of supporting the scrotum and re-
ceiving the discharge, which passes chiefly downwards. The
106
ASEPTIC SURGERY.
hollows having been filled np with loose gauze, the general
dressing is applied. A hole is cut in this dressing towards the
Fig. 51.— Deeper part of the hernia and scrotal dressings.
Left side of Bcrotum covered with gauze soaked in carbolised glycerine. Mass of gauze in the
perineum enclosed in a roll of gauze.
upper border, and the penis is passed through this hole, and
thus helps to keep the dressing in position. The dressing
„., 'l!£LlmMM/jJ,/Jj^/^/^^^jj^^^
Fig. 52. — Dressing in a case op operation for hernia, or on the
scrotum on the LEb'T SIDE, SHOWING THE ARRANGEMENT OP THE
DRESSING AND ELASTIC BANDAGE.
passes over the scrotum and over the perineal pad, and is fixed
bv a double spica bandage (Fig. 52). The pad in the j)eri-
EXCISIONS OF JOINTS.
107
neum is fixed there by a St. Andrew's cross. The elastic band-
age is applied in the form of a St. Andrew's cross in the peri-
neum, and of a double spica (Fig 53). The bandages, dress-
ing, and perineal pad are carefully pinned together in the
perineum.
The methods of managing excisions of joints^ operations for
ununited fractures, &c., in the lower extremities, are very im-
portant. Here jjerfect rest must be combined as far as possible
with the aseptic treatment. For two or three days after an
Fig. 53. — Dressing in hernia cases or in operations on the scrotum,
showing the arrangement op the bandages in the perineum.
(seen from BELOW).
operation it is better to change the dressing, which is the
ordinary gauze dressing applied round the limb, simply by lift-
ing the limb, because there is generally a large amount of
bloody and serous oozing at first. After a few days this
oozing has become much diminished in amount, and the
dressing is then accomplished in the following manner : — A
Gooch's splint is padded above and below the situation of the
wound, the part opposite the wound being left unpadded. The
whole splint and padding is covered with a piece of macintosh
cloth, and is firmly fixed to the posterior aspect of the limb
above and below the situation of tlie wound. Behind the
wound, at the part where tlif jjadding is deficient, masses
10.H
ASEPTIC SlTIiGEliY
of gauze of sufficient thickness are arranged transversely and
superficial to the macintosh. These pieces are three or four
or more in number, and they act as padding for the splint,
and at the same time as an antiseptic dressing (Fig. 54).
When the dressing is changed, a piece of gauze is pinned to each
Fig. 5i.— Splint for excision of knee, ready for application.
The splint is padded at the upper and lower parts, and tlie splint and padding are covered with
a piece of macintosh cloth. The space opposite the knee is filled with masses of gauze
arranged transversely and superficial to the macintosh.
of the old pieces, and then the old piece being pulled out the
new is pulled in, and thus the limb is never left without
support (Fig. 55). Over the front of the limb an ordinary
gauze dressing of suitable size is applied.
Splint applied in a case op excision op the knee.
This shows the method of changing the dressing. In the first way described a mass of gauze
would be pinned on to the end of the old piece on the other side of the limb, so that as the
old piece is pulled out the new is pulled in, or it may be arranged in the second manner de-
sc^ribed, and shown in Fig. 54— viz., a piece only extends to the middle line behind, and as
soon as each is pulled out afresh piece is pushed in.
Another more convenient way in which this may be
managed with even less movement is to have each of the
masses of gauze mentioned in the former paragraph divided, in
the middle line, and thus the half of each mass is pulled out
at a time and a new piece substituted (Fig. 54).
TREATMEXT OF ABSCESSES. lO'J
Another way is to apply a wire splint next the skin, fix it
there, and then apply the dressings outside.
When the discharge becomes still less the limb may be put
up in plaster of Paris, a window being left for dressing.
Excision of joints is now, however, rarely performed, for
with aseptic treatment an incision into a joint and the insertion
of a drainage tube is generally sufficient in cases where formerly
excision or even amputation would have been required. Several
advantages are thus gained, among the most prominent of these
being absence of shortening of the limb (and this is most im-
portant in children), and often a certain and even a considerable
amount of motion in the joint afterwards.
It may be mentioned here that Mr. Knowsley Thornton in
ovariotomy cases does not apply a bandage round the abdomen.
He fastens the dressing with adhesive plaster, and does not
change it for a week, by which time healing is generally
complete, except where the stitches are.
Such are the chief points as to the application of antiseptic
dressings in different situations. I must now say a few words
as to the aseptic treatment of abscesses.
I have already referred to the question of the necessity for
a dependent opening, and I pointed out that, as the discharge
from an abscess treated aseptically is not irritating, because not
putrid, it does little harm even though left to well out, instead
of being permitted to flow ou.t through a dependent opening.
In fact, aseptic surgery has altered the relative importance of
the questions to be considered in selecting a situation for open-
ing an abscess ; and now the chief point to be looked at is not
whether the orifice of the tube is in the most dependent position
possible, but whether it is at the point furthest removed from
sources of putrefaction — i.e.. whether there is the greatest pos-
sible space for the overlapping of the antiseptic dressings.
Indeed, in some abscesses pointing near such canals as the
pharynx, anus, &c., it is better to make an opening in healthy
structures at some distance from the abscess, and burrow a
channel into it, than to make an incision directly into the
abscess cavity.
I saw a striking example of tliis iu Kdiubui-gh se\cral vears
110 ASEPTIC SURGERY.
ago. A boy was admitted into the infirmary with retropha-
ryngeal abscess connected with occipito-atloidean disease. The
abscess was on the point of bursting into the pharynx. Mr.
John Chiene, who had charge of the case, instead of opening
the abscess at the only place where it was pointing, viz., in the
pharynx, cut down behind the sterno-mastoid, and burrowed into
the abscess cavity from behind. The abscess followed a typical
aseptic course, and the patient recovered completely. Thus
then the great rule in selecting a situation for opening abscesses
is to make the incision as far as possible from sources of
putrefaction.
When opened, instead of dealing tenderly with the pyogenic
membrane as was formerly done under the impression that it
was a hurtful thing to injure it, we now empty the cavity
thoroughly, especially in the case of chronic abscesses, in order
to get out all curdy masses of pus, &c., which may have gravi-
tated to the bottom of the abscess. When this is done oppor-
tunity is given for, the rapid adhesion of the greater part of the
wall of the abscess cavity, and thus in a very short time there
is merely a sinus left leading down to the seat of disease.
There is no necessity for washing out the cavity of an
abscess, as is done in so many quarters. To do so is simply to
irritate the pyogenic membrane unnecessarily without securing
any corresponding benefit. Indeed, it might give rise to such
an amount of oozing from the wall of the abscess as would wash
out all the carbolic acid from the dressings in a very short
time, and thus lead to the putrefaction of the discharge. The
treatment by hyperdistension, while erroneous in theory, is
very dangerous in practice, as the fluid may be forced into the
cellular tissue, and lead to diffuse inflammation and even
gangrene, or to carbolic acid poisoning and death.
The greatest care must be taken in the drainage of abscesses.
In the case of a large psoas abscess the surgeon should intro-
duce the largest sized drainage tube in the first instance. This
tube may be changed for a smaller in a few days. It ought not
to be removed for the first time till at least three days have
elapsed since the abscess was opened, otherwise there may be
great difficulty in replacing it. It should not be shortened till
it is found to be absolutely impossible to get it in fully. When-
TREATMEXT OF ABSCESSES. Ill
ever this is the ease a piece must be cut otif from the end.
(Here I speak of chronic abscesses, an acute abscess heals in a
week or ten days.) In some cases, where the same tube is
left in for a week (where the case is only dressed once a week),
some difficulty will be found in withdrawing it, owing to the
granulations having grown in at the holes and holding it in
position. In this instance the guide as to shortening is lost,
because the tube cannot be pushed out ; and therefore it will
be found best in old cases to use a tube having holes only
close to its inner end. This cannot be held, and is gradually
pushed out as the sinus heals from the bottom. If on removal
of a tube the discharge is found to increase in quantity, the
tube must be reintroduced.
As the incision into the abscess is merely large enough to
admit the tube, there would be no reason for using protective ;
and therefore the wet gauze is applied directly over the orifice
of the tube. A tube is the only form of drain suitable in
these cases.
The precautions required in order to ensure an aseptic result
are precisely the same as in the case of wounds.
In changing the dressings the same rules are followed as
were formerly described with regard to incised wounds. Chronic
abscesses, more PS]>ecially abscesses connected with diseased
bones, are extremely tedious ; but nevertheless, as a rule they
ultimately recover. The same care must, however, be taken
from first to last. It is never safe to change the carbolic
dressing for a boracic one, however superficial the wound ap-
pears to be. In the case of spinal abscesses absolute rest in
the recumbent posture must be maintained till healing is com-
plete ; and as the cases generally extend over many months it
is well to warn patient and friends before commencing to treat
the case. Whether the rule as to the maintenance of the
recumbent posture may not be modified by the use of Sayre's
jacket, or even without it, is now a question. Lately in two
cases which had been under treatment for a long time, and in
which all uneasiness in the spine had passed off, Mr. Lister
allowed the patients to get up before healing was complete,
and without any bad results.
Empyema does particularly \sv\] under this dressing. I
112 ASEPTIC SUllGERY.
mention it, in order to state that a metallic drainage tube with
a shield like a tracheotomy tube, and with lateral holes, is the
best because the india-rubber tube may get compressed between
the ribs or be too abruptly bent where it passes into the interior
of the pleural cavity.
There are some cases in which neither the gauze dressing
nor the boracic can be employed, but which may nevertheless
be treated aseptically. I refer especially to abscess in the
perineum or by the side of the anus.
Abscess in the perineum may be treated aseptically with
very satisfactory results. The abscess is opened under the
spray, and a piece of lint dipped in 1-5 carbolic oil or 1-10
carbolic glycerine is introduced into the cavity to act as a drain.
Outside this two or three layers of lint soaked in 1-5 carbolic
oil or 1-10 carbolic glycerine are applied, and fixed with a T
bandage. Should this become displaced or wet with urine, e^c,
the patient pours a little carbolic oil or glycerine over the
wound and over the lint, and replaces the dressing. No spray
is required in changing the dressings. On the third day a
piece of lint dipped in carboHc oil is laid over the wound, and
a pair of oiled forceps is slipped under the lint to seize and with-
draw the plug ; or the plug may simply be pulled out under
the spray. Carbolic oil or glycerine 1-10 is then used for
dressino-, and when the wound has become superficial boracic or
salicylic ointment is employed.
The same method of dressing is employed in abscesses
beside the anus. In this case, when the patient defsecates, he
holds aside the dressing, defeecates past it, wipes the parts with
1-20 carbolic lotion and then with 1-10 carbolic oil. He then
soaks the dressing with the oil, or applies a new dressing.
(The glycerine and carbolic acid may also be used.) The result
of this method of treating these abscesses is often excellent,
fistula in ano being apparently often avoided when the abscess
is taken in time.
So much for wounds made by the surgeon and their treat-
ment. I now come to the consideration of tuounds 'produced
accidentally. Here the problem is different from and much
more difficult than the former. In the cases we have just
WOUNDS PRODUCED ACCIDENTALLY. 113
been considering we had merely to keep out the septic particles ;
in the present instance these particles have already gained
admission, and therefore we have not only to prevent the
entrance of more but also to destroy those ah'eady present.
This is done by washing out the wound with 1-20 carbolic
lotion, provided it be recent, i.e., made within twenty-four
hours, and then treating it like a wound made by a siu-geon.
This washing out of the wound must be done very
thoroughly. It is best carried out by using a syringe with a
catheter attached to it. The point of the catheter is intro-
duced into all the recesses of the wound and the 1-20 lotion is
injected through it, and thus comes thoroughly in contact with
all parts. There must be no attempt to distend the cavity, as,
for instance, by shutting the orifice of the wound around the
syringe, for the fluid might be forced into the cellular tissue
and lead to inflammation or even sloughing. The opening
must be left perfectly free and enlarged if necessary. Should
there be any shreds of tissue, they had better be cut off, and if
there be much dirt ground into the tissue, it must be got rid
of by means of a nail brush. The injection and the subsequent
procedures are carried out under the spray.
If the wound was made twenty-four to forty-eight hours
before being seen, a stronger solution is employed, viz., the 1-5
spirituous solution. This is used in the same way as the
other.
Having thus got the wound pure the question of stitching
it up arises. The answer to this question varies according to
the parts injured. As a rule, in injury of the soft parts, a
drain is introduced, and the same accurate stitching employed
under the spray as was described on a former page. More
especially is this the rule in scalp wounds, where most brilliant
results maybe obtained by the use of catgut drains and accurate
stitching. The rest of the treatment is the same as in ojiera-
tion wounds.
Where the wound is much contused, the same rules apply
as to purification, but it must not be stitched up. After purifi-
cation a drainage tube is inserted if necessary, the wound is
lefto],)en, a piece of protective is placed over it, and the dressing
applied in the usual manner.
1
114 ASEPTIC SURGERY.
I have mentioned the methods to be employed when the
womid is seen within the first forty-eight hours. It may be,
however, that it does not come under notice till putrefaction
already exists. In this case it may be purified by the intro-
duction of iodoform suspended in water by the aid of ;dcohol,
or if superficial, by stuffing it thoroughly with lint dipped in
1-5 carbolic oil. This dressing repeated for several days
generally converts it into an aseptic wound. In most cases it
is best to apply iodoform or the chloride of zinc solution.
Certain special wounds call for attention.
Compound fractures are the wounds in which this treat-
ment was first applied, and in which excellent results can be
obtained. There are a few special points to be noted. In
purifying the wounds great pains must be taken. Any dirt
• must be carefully scraped or scrubbed out. All blood clots
ought to be turned out as completely as possible. The ends of
the bones are cleaned, and if they cannot be returned or got to
fit, portions should be sawn off. The ends may be tied together
with silver wire. The parts ought to be well kneaded as the
carbolic lotion is injected through the catheter, in order to
diffuse the lotion as much as possible into all the recesses of
the wound. No stitches are inserted, but on the contrary, free
drainage by tubes is used. The same sort of dressings and
apparatus are employed as in excisions.
Wounds involving tendons, nerves, or muscles, are treated
in the same manner as others, and the ends of the divided
muscles, tendons, or nerves, ought to be stitched together
with catgut, and the position of the part so arranged as to
avoid dragging on these stitches.
Wounds of joints are very imj^ortant. When recent no
operation (excision or amputation) is required in the first
instance. As a rule the joint may be saved, and perfect move-
ment obtained by washing it out very thoroughly with carbolic
lotion 1-20. The wound in the joint is enlarged if necessary.
Where several hours have elapsed since the accident (more than
eight or ten hours), it is well to employ the sj)irituous solution.
A drainage tube is introduced into the joint, but no stitches
are used. After a few days, when the discharge has diminished,
SPECIAL WOUNDS. 115
the drain is removed. In about three weeks, or earlier, passive
motion ought to be begun, otherwise the adhesions outside the
joint may become so strong as to require to be broken down
under chloroform.
Compound fractures of the skull are treated in the same
manner as compound fractures elsewhere, purification being
attempted with 1-20 carbolic lotion. The dm-a mater may
be freely dealt with without fear of inflammation, for the
irritation of carbolic acid is only very transient. Bleed-
ing vessels are secured by catgut. Should one of the great
sinuses be wounded, a graduated compress of catgut arrests the
haemorrhage satisfactorily. This I have known to act very well
in a case of woimd of the longitudinal sinus, occurring during
the operation of trephining over the seat of an old injury.
Wounds penetrating the thoracic cavity are much more
difficult to treat. Should the wound penetrate the lung, and
should the lung protrude, the exposed parts and those around
are purified with carbolic lotion 1-20. In deciding as to the
returning of the injured lung and the stitching up of the wound,
the surgeon must be guided by the circumstances of the par-
ticular injury. In some cases, if the wound in the lung were
superficial, the edges of the divided visceral pleura might be
stitched together with fine catgut, the lung returned, and the
external wound closed. Where a large bronchus is injured it
might be better practice to leave the limg in the wound, and
leave the wound open.
Where there is merely a wound of the parietal pleura, and
where the lung is not wounded, the external wound only is
purified and is closely stitched, in the hope that union by first
intention may occur, that the air may be absorbed, and that
any septic dust present in the pleural cavity may be unable to
cause mischief.
Wounds of the abdomen are variously treated, according as
there is or is not protrusion of the contents. Where there is
no protrusion, and where there is no reason to suspect injm-y of
the viscera, the external wound ought to be purified and
closely stitched, so as to get primary union throughout, no drain
being used.
Where the intestines protrude, they ought to be carefully
116 ASErriC SURGERY.
bathed in warm carbolic lotion 1-30 or even 1-20, and if there
be no injury of them in any part they may be returned. If
they are cut, the gut may be stitched with catgut by the
glover's suture.
If the omentum protrudes, opinions vary as to the treat-
ment. When it can be returned do so after thorough purifica-
tion, and then stitch the abdominal walls, including the perito-
neum, close together. Where, from adhesion or other sufficient
cause, this cannot be done, or where the omentum is very
dirty, I should, from a research into the consequences of un- .
returned omentum by Dr. Kenneth McLeod, of Calcutta, con-
sider it the safest practice, especially in the case of a person
with strong muscular parietes, to stitch the deepest parts of
the omentum to the deep part of the wound, cut off the
remainder and close the skin over all.
If internal haemorrhage is going on, apparently from the
mesenteric vessels, the wound may be enlarged and the bleeding
point sought for. Simon advised that in bleeding from the
kidney, the injiu-ed organ should be excised ; this suggestion
was never put into practice, but nevertheless it is one well
worth bearing in mind.
Such are the chief points to be attended to in recent
wounds ; there remains for consideration the class of cases in
which putrefaction has been present for a long time. I refer
to cases of putrid sinuses, generally connected with diseased
bones or joints. An attempt may be made to purify these
during the course of an operation, and sometimes when the
sinuses are few and uncomplicated, and where all the dead bone
is removed, this attem})t may be successful. The sinus is
scraped out with one of Volkmann's sharp spoons (Fig. 56), and
all the granulation tissue, as far as possible, removed. The
raw surface of the sinus, &c., is then washed out with the
chloride of zinc solution, which is applied thoroughly to all
parts, and a gauze dressing is used, in the hope that putre-
faction has been thus eradicated. The spray should be employed
during the whole procedure.
If this is successful, well and good. If not, boracic oint-
ment (at first full strength, afterwards half) or salicylic oint-
TREATMENT OF BURNS. 117
ment, covered with boracic lint, is the best dressing, indeed, it
is the best dressing in all cases where strict aseptic measures
are inapplicable.
The aseptic treatment of burns varies according to the
degree and extent of the injury. In any case, unless where
the burn is very extensive and where the parts are extremely
dirty (necessitating scrubbing of the surface and consequent
shock, and also risk of carbolic poisoning), an attempt should
be made to purify the surface with 1-20 carbolic lotion. This
having been done, if the surface is small, boracic ointment (full
strength) and boracic lint form a convenient dressing. When
the extent of the burn is greater, wet boracic dressing (wet
boracic lint used as water dressing — covered by gutta-percha
Fig. 56.— Two foejis op sharp spoons, a large round one akd a
small oval one.
tissue or macintosh) is the most suitable. The wet boracic
dressing is also applied in those cases where, on account of the
extent of the burnt surface and the amount cf dirt, purification
with carbolic acid is not advisable. Where the surface is
thoroughly charred and where the wound is not very extensive,
boracic ointment or carbolic oil 1-10 are the best dressings.
The objection to carbolic oil, which was formerly used in all cases,
is that, when the surface is large, there may be a fatal absorp-
tion of carbolic acid.
In the after-treatment the sores are dressed with boracic
dressings (protective and boracic lint, or better, in the first
instance, boracic ointment) just as in the case of ulcers.
The rules as to the treatment of gangrene are altered in
118 ASEPTIC SURGERY.
aseptic surgery, and this is more especially the case with senile
gangrene. Should symptoms of senile gangrene set in, say in the
lower extremity, the skin of the foot, toes and leg, are
thoroughly cleansed with 1-20 carbolic lotion. This must be
done very efficiently. All the folds about the nails, &c., must
be carefully cleansed and washed. This having been done, the
whole limb and foot are enveloped in a large mass of carbolised
cotton wool (carbolised in a 1 per cent, ethereal solution of
carbolic acid). This being pure in its substance, and being
applied over a pure surface, completely shuts out causes of
putrefaction. The carbolic acid soon flies off, and then the
cotton wool acts simply as a filter, while it protects the part
from unequal pressure and retains the heat. This may be
kept on for any length of time, and so long as discharge does
not extend to the surface or the gangrene above the limits of
the dressing, the part remains sweet, and very often the gan-
grene, which in the first instance threatened to involve the
whole leg, becomes limited, and there may even be merely a
small cutaneous slough. In any case, as a rule, the gangrene
does not go on spreading as it does when treated in the usual
manner, and for this reason : — Suppose that the part is not
treated aseptically, the tissue at the edge of the dried gan-
grenous mass becomes putrid, the living tissue in the neigh-
bourhood is very weak, the putrid material acts on it like a
caustic, destroys its vitality or excites an inflammation which
kills it, and so the gangrene goes on spreading, till at length
parts are met with of sufficient vitality to resist this action of
the putrid materials. Then a line of demarcation is formed.
On the other hand, when the gangrenous parts are not putrid,
the weak parts in the vicinity, which would to a certainty
have died in the former case, retain their vitality and gain
strength. Thus also the rule of never amputating in senile
gangrene, except to trim a stump formed naturally, is done
away with, and it is generally better to amputate as soon as
it is clear to what extent the tissue is dead, rather than to
subject the })atient to the continual pain and irritation arising
from the presence of the dead piece. The same reasoning
a])plies to cases of traimaatic spreading gangrene. This is
only one instance of how completely many current ideas as
TREATMENT OF N.EVI, ETC. 119
to surgical pathology and treatment are reversed, when means
are taken to render the dust of the atmosphere inert before it
reaches a wound.
In treating nasvi great benefit is obtained from the in-
jection of pure carbolic acid. The na3vus is first thoroughly-
cut off from the circulation by ligatures tightly applied around
its base, and then half minims of pure carbolic acid are in-
jected into various parts of the tumom-. Ten minutes or so
having been allowed to pass, in order to ensure com])lete and
firm coagulation, the ligatures are divided and removed, and the
punctures are touched with collodion. The surface being left
completely dry, any slough which forms becomes absorbed or
separates as a crust after some time, the part beneath being
found to be a scar.
The same method answers excellently in the treatment of
varicose veins. A tourniquet having been firmly applied around
the upper part of tlie limb in order to arrest the circulation,
the vein is punctured at various parts, and half minims of car-
bolic acid are introduced into it. The tourniquet is kept on
for ten minutes after the injection is completed. Coagulation
and a slight degree of inflammation are thus induced, but this,
so far as I have seen, never goes to any dangerous extent, and
is followed by at least temporary cure. I have not known
any case return with reformation of varicose veins.
A dissection or post-mortem wound does not give rise to
bad results if the wound be instantly purified with 1-20 car-
bolic lotion.
120 ASEPTIC SURGERY— MODIFICATIONS.
CHAPTER VI.
ASEPTIC SURGERY — MODIFICATIONS.
Country practice : Hoiv to dispense, with the sjjray diinng the operation — and
during the after-treatment : How to render the dressings less frequent. Is
the aseiDtic method applicable in war? Mr. Lister's svggestions :
Esmarch''s2)lan : Reyher's method. Development of Aseptic S>Trgery in ]Mr.
Lister's hands : Conipoimd fractures — Pure carbolic acid — Formation of
crust — Carholic p%dty — Lead plaster — Lac plaster, syringing wounds with
carVolic lotion, protective, catgut ligat^ires, method in 1870 — Present method
in tlis main introduced in 1871 — Fwther introduction of wet gauze, steam
spray, elastic bandages : abscesses — Method of opening them under carbolic
oil : wounds.
Such are the methods usually employed in carrying out the
Listerian principle in hospital or in private practice. It is,
however, said to be difficult of application to country practice,
and we must therefore enquire in what way it can be made
easier. The difficulties urged are that the spray is too heavy
to carry : that it is not always easy to return a long distance to
see a patient on the day after the operation, and that the dress-
ings are too expensive for the lower classes. We must there-
fore, in some way or other, render the dressings very infrequent,
so as to avoid expense and unnecessary visits, and we must try
to dispense with the spray.
In the first instance in going to perform an operation or to
treat a wound, the surgeon takes instruments with him, and he
may, without any additional trouble, easily add a spray to the
contents of his bag, and this spray may be left at the patient's
house, and brought home again after the first dressing. But,
suppose the surgeon has not a spray at hand. What is to be
done ? Well, he must use all the other i)recautions before
described, and wash out the wound frequently with 1-40
carbolic acid lotion during the operation, and while the stitches
MODIFICATIONS FOR COUNTRY PRACTICE. 121
are being inserted ; and then, before the piece of wet gauze is
applied, he may distend the wound with the same lotion, the
wet gauze being applied while this is still flowing out. At
the same time I caimot see that, in the great majority of cases,
it can be any great hardship to carry a spray to an operation.
During the after-treatment a spray is not necessary. The
spray may be rendered unnecessary diuring the after-treatment
in two ways. In the case where catgut stitches and catgut
drains are used a deep dressing may be applied at the time
of the operation, and may never require to be changed.
This deep dressing is fixed down in some way or other, and is
treated as a wound, the gauze being soaked with carbolic lotion
every time the superficial dressing is removed, and then a
piece of wet gauze larger than the deep dressing, and the
general dressing are applied. Should it be necessary to remove
the deep dressing, there is no necessity for the spray, if catgut
drains be used, because there is no cavity into which air may
pass. The deep dressing having been removed, carbolic lotion
is allowed to flow over the wound till a guard is applied.
Where a tube is used it is more difficult to do without the
spray, for in that case there is an open orifice into which dust
may fall, and be sucked into the interior of the wound, and
further, when the tube is removed, air must enter to take its
place. This may be avoided by the use of a syringe which
constantly keeps a stream of carbolic acid lotion passing over
the wound and over the drainage tube, till a fresh dressing
is applied. Should it be necessary to remove the tube it is
well, in addition to this constant flow of lotion, to cover the
orifice of the tube with a rag dij^ped in the antiseptic lotion.
The best way is to take a guard soaked in carbolic lotion and
folded in several layers, and place this over the orifice of the
drainage tube, extending on each side of it for a considerable
distance. The tube is now seized with a pair of forceps through
this rag, and as it is pulled out the rag is carefully tucked in
around it, so as to compel the air, as it passes in to take the
place of the drainage tube, to traverse the moist guard. This
seems to me better than the method of slipi)ing in forceps
under the guard and pulling out the tube, the guaid being well
pressed down on it. In taking out wire or silk stitches, the
122 ASErilV SURGERY— MODIFICATIONS.
guard is pulled aside so as to expose the stitch, a little carbolic
lotion is then dropped over the suture, and as the latter is
withdrawn, a few drops of the lotion are applied to the orifice
of the puncture.
These methods — the use of catgut stitches and catgut
drain, and the employment of a permanent deep dressing,
together with the hints in cases where a drainage tube or non-
absorbable stitches are employed, suffice to render the operator
independent of a spray.
Can we now render the dressings less frequent ? This may
of course be done to a certain extent by applying a larger
amount of gauze, but the best way is to use sponges in the
interior of the dressing for the purpose of absorbing and retain-
ing the fluid. The deep dressing having been applied and
fixed, a large sponge or several small ones are placed outside it,
these sponges having just been wrung out of carbolic lotion ;
outside the sponges and extending well beyond them is a piece
of wet gauze, and then the masses of loose gauze and general
gauze dressing. In this way the discharge is retained in the
interior of the dressing, and of course so long as it is there,
and so long as the discharge has not reached the edge of the
dressing, it is as safe from putrefaction as if it were in a pure
flask. By the use of these sponges several days may be
allowed to elapse, in many cases, before the first dressing is
changed, though it is well in every case to change the first
dressing on the day after the operation. When the dressing
is changed these sponges are squeezed thoroughly, washed in
carbolic lotion 1-40, and reapplied. By the use of sponges two
or three dressings suffice for the treatment of most operation
wounds.
By the use of salicylic jute in large masses, the same avoid-
ance of frequent dressings may be obtained, but this material
is not very trustworthy as an antiseptic.
Thoroughly purified cotton wool, which may be obtained
cheaply by impregnating it with sulphurous acid fumes, ap-
plied in large mass may prevent the necessity of frequent
dressing.
By the means described, the difficulties in the way of the
adoption of this system in country practice may be overcome.
APPLICATION IX JVAP. 123
and instead of causing additional expense to a poor patient, it
saves expense in many ways. The dressings required are so
few that the price of the materials employed is not greater
than that which would be necessary even if water dressing
were used ; and expense is saved in many other ways, as I shall
mention in the latter part of this work, notably in the rapid
healing, which is of course of the greatest consequence to the
bread winner.
Is the Aseptic method applicable in War"?
In the 'British Medical Journal ' for September 3, 1870,
Mr. Lister describes a method for the use of army surgeons.
He suggests that the wound should, as soon as possible after
the injury, be thoroughly washed out with 1-20 carbolic lotion,
the smTounding skin being at the same time purified.
Bleeding vessels are secured by catgut, by torsion, or by car-
bolised silk. While the wound is full of lotion, extract the
bullet, clothes, &c. Then cover the wound with two or three
layers of oiled silk, smeared on both sides with carbolic oil 1-5.
Over this apply layers of lint soaked in the 1-5 oil. overlapping
the oiled silk for about three inches in every direction, and
about a quarter of an inch in thickness. This is covered with
gutta-percha tissue, and the whole is fastened on with a bandage
soaked in carbolic oil. This is the permanent dressing. Out-
side this, another and larger dressing of oiled lint covered by
gutta-percha tissue is applied daily. During the first day apply
fresh oil to the outer cloth once in six or twelve hours. On
the following day the outer dressing is changed, carbolic
lotion being introduced under the edge, as it is lifted, by
means of a syringe ; or carbolic oil may be poured in. After
the first dressing use the 1-10 oily solution, and later the
1-20. On the second day oil is only applied once in twelve
hours, after that it is applied daily for five or six days, and then
once in two days.
Jn compound fractures use a wire splint next the deep
dressing, and apply the fresh superficial dressings outside the
wire. This s})lint need not be removed till union is complete,
the oil being merely poured between the meshes when the
dressing is changed.
124
ASEPTIC SURGER Y—MODIFICA TIONS.
APPLICATION IN WAR. 125
Esmarch, in Langenbeck's ' Archiv,' vol. xx. p. 171, proposes
another plan of treatment.
He points out that the new form of bullets passing quickly
through the clothes may not carry into the wound any causes
of putrefaction. Therefore, if the wound is not examined by
dirty fingers or instruments, and if it be seen at once, it may
in most cases be regarded as aseptic. Starting on this prin-
ciple, he suggests that each soldier should be provided with
tampons of salicylic cotton, wrapped in salicylic gauze. Fig.
•57 represents the contents of the packet of dressings which
Esmarch proposes to supply to each soldier. At the front, when
there seems any possibility of saving the limb, these tampons
are introduced into the openings, and bandaged on without
any preliminary probing or examination of the wound. Any
other necessary apparatus is applied, and the patient sent to
the rear. At the rear the skin around the orifice is purified
with some antiseptic lotion, and if there is any necessity to
explore the wound, as for removing bullets, splinters, &c., the
tampon is removed under the spray, the wound washed out,
and an antiseptic dressing applied. If there is no necessity
for exploring the wound, the skin is merely purified, and
then a mass of salicylic jute or other antiseptic material is
applied without disturbing the tampon. If putrefaction occurs
later the wound must be enlarged, and an attempt made to
purify it.
Conservative surgery being more a})plicable with the aseptic
method, the necessity for primary amputation at the front is less
frequent, and as a rule exists only in the case of sjnashes from
large balls. Esmarch considers that for such cases a sutficient
supply of antiseptic materials should be present in the am-
bulance. Referring to those cases not treated aseptically which
do well, and to the evils of investigating the wound at the first,
Esmarch says : ' So weit ich habe in Erfahrung bringen kon-
nen sind diejeningen Kalle, welche asei)tisch verliefen, auf
dem Schlachtfelde nicht mit dem Finger griindhch untersucht,
sondern gleieh verbunden worden, wahrend solche Falle bei
denen wiederholte Untersuchungen vorgenommen waren, mir
oft einen besonders schlimmen Verlauf zu iiehmen schienen.'
Esmarch's method has been put to the test by Dr. Reyher
]2G SEPTIC SURGERY— MODIFICATIONS.
during the late Kusso-Turkish campaign. His results were
excellent, and will be referred to later on. He carried out the
aseptic method in two ways, according to the nature of the
injury and the treatment before the case came into the sur-
geon's hands. These are, either that the surgeon closes the
wound without further treatment, merely disinfecting the sur-
rounding parts, or else that he cleans out and purifies the track
of the bullet, and afterwards makes provision for free aseptic
drainage. In the first instance healing occurs under a crust ;
in the second, under a moist and antiseptic dressing.
The cases which are suitable for the first method of treat-
ment— treatment by a crust — are those in which the wound is
small, where no clothing has been carried in with the bullet,
where the edges of the wound fall together as where the
wound is more or less valvular, and where no examination of
the wound by finger, probe, &c., has been made. In such a
case the surrounding skin is carefully purified, and an attempt
is made to obtain a dry crust either by allowing the blood to
dry, or by aiding the drying by applying charpie, gauze, &c. ;
or the wound may be covered by a mass of salicylic wool or
carbolic gauze. Keyher lays particular stress on the avoidance
of probing or draining such wounds. On the contrary, any
communication with the outer world should be shut off as soon
as possible.
In many cases this ' occlusion ' of the wound cannot be
depended on, and the bullet track must be washed out, and
treated in the way described under compound fracture, free
drainage being carefully provided. This is chiefly the case
where the missile has been travelling slowly, and where, conse-
quently, the wound in the skin is not so small nor valvular, and
where there is more likelihood of articles of dress being carried
in with it ; where, also, as Eeyher puts it, the wound is open
and ' the air has not only entered but must enter again.' This
treatment is also necessary in cases where wounds have been
examined with unclean fingers or instruments before reaching
the ambulance.
It is thus evident that the spray is not required for the
majority of cases, and indeed by following the lines previously
indicated it may be entirely dispensed with. The gauze re-
ATTLICATION IN WAR. 127
quired for the dressings can be made in the vicinity, and for
this purpose Eeyher carried with him the machine for making
gauze described in Chapter III., and had thus a constant supply
of the freshly-prepared material. There is not much difficulty,
therefore, with regard to the materials ; the real question is
how to have the cases treated aseptically from the very first.
Eeyher was able to overcome these difficulties by proceeding in
the following manner. In the first place, instructions were
given that wounds were never to be examined at the front,
either with fingers or instruments, nor was any attempt to be
made to extract a bullet. The only exceptions to these rules
were cases where blood-vessels were injured, though even in
these it was generally possible to apply an Esmarch's elastic
band to control the haemorrhage temporarily ; and cases where
the projectile had passed into the large cavities of the body,
and, without wounding the contents, had remained in the wall
of the cavity. In such a case the bullet ought to be extracted
at once, lest it should fall into the cavity during the transit of
the patient. ' For surgeons at the front there is only one line
of treatment — to occlude the wound provisionally — to lay the
wounded part in a suitable position on the litter, and to render
it provisionally immovable. As provisional dressing the sali-
cylic balls recommended by Esmarch are the best.' This
method is chiefly suitable for cases where the soft parts alone
are injured. ]Most of the serious cases can be attended to as
a rule at the foremost ambulance.
The more surgeons become imbued with the true principles
of aseptic surgery, and the more thoroughly they grasp anti-
septic surgery in all its developments, so much the greater is the
likelihood of obtaining aseptic results. Reyher's results show
strikingly what can be done with the methods at present at
our disposal. There can be no doubt that with improved
methods and increased knowledge and experience, aseptic
surgery will soon be universally carried out in war.'
It will be interesting now to trace the gradual development
' For a resume of the opinions of army surgeons on the best methods of
carrying out aseptic surgery in war, see a little pamphlet by Surgeon- Major
H. Melladew, Xvtcson Antincptie Surgery in War. London : Ilanken ."v Co. 1881.
128 ASEPTIC SURGERY.
of this system in Mr. Lister's hands. This will not only be
interesting but instructive, as showing how aseptic surgery
may be carried out in circumstances where spray, gauze, &c.,
cannot be obtained.
• The first cases in which the treatment was tried were com-
pound fractures, and the first attempt recorded by Mr. Lister
was made in March 1865. This attempt was imsuccessful, as
Mr. Lister subsequently believed, from mismanagement.^ The
next case was a compound fracture of the tibia, caused by the
wheel of a waggon passing over the leg. The external wound
in this case was 1^ inch long, and | inch broad. A piece of
lint dipped in carbolic acid (which was at that time only got
as an impure liquid known as German creosote) was placed
upon the wound. Four days later this lint was removed, and
the wound dressed with lint soaked in water in which this im-
pure carbolic acid was diffused. Five days afterwards a solution
of one part of carbolic acid in from 10 to 20 parts of olive oil
was used for four days, and then ordinary water dressing was
resorted to.
The aim in this case was to form a crust consisting of lint,
carbolic acid, and blood, which would protect the deeper parts
from putrefaction. In this instance, however, the scab came
off on the fourth day, and in order to avoid this occurrence,
Mr. Lister, in his next cases, applied a piece of lint dipped in
pure carbolic acid as before, large enough to overlap the sound
skin for a quarter of an inch all round, and covered with oiled
paper, applying for the first four days outside this arrangement
a piece of lint soaked in pure carbolic acid. The crust was
left untouched till the eleventh day, and then water dressing
was used.
It now became evident that, owing to the volatility of the
carbolic acid, means were required to prevent its evaporation.
Accordingly, in the next cases a layer of sheet lead or of block
fin was applied outside and overlapping the crust.
Up to this time there was no attempt made to purify the
interior of the wound in the first instance. How was it, then,
that no putreftiction occurred ? Probably for the following
reasons. It may have been that no septic particles had got
' See numbers of the Lancet for 1867.
ITS DEVELOPMENT. 129
into the interior of the wound because the blood flowing con-
stantly out would prevent the entrance of solid particles, which
would thus only be present if dirt was introduced at the time
of the accident, or if much movement of the fragments oc-
curred afterwards, with consequent introduction of air. Further,
if any septic particles were present they may not have been
able to produce any effect in the presence of healthy living
blood clot. (This will be discussed hereafter.) Lastly, the
strong carbolic acid, though appKed only to the surface, rapidly
spreads into the interior even to a depth of one or two
inches.
The necessity for pmifying the deeper parts of the wound
soon became evident. A case was admitted in which, when the
tissues around the wound were pressed, bubbles of air escaped
along with the blood. Here Mr. Lister squeezed out as much
of the clotted blood and air as he could, and then applied a
piece of lint dipped in pure carbolic acid, slightly larger than
the wound, and over this the piece of block tin. The crust
was daily painted with carbolic acid, the tin cap being reap-
plied on each occasion. This treatment was continued for
three weeks.
This purification of the deeper parts was carried out more
thoroughly in the next case, in w^hich it was necessary to saw
off a portion of the ulna, and here the whole of the interior of
the wound was swabbed out with pm-e carbolic acid. In this
case Mr. Lister first became acquainted with ' antiseptic sup-
puration,' i.e. su})puration due to the irritation of the anti-
septic applied. (The evil effects of the piure caustic carbolic
acid in causing excoriation of the skin had been already
noticed.)
Finding that no harm resulted from the free application of
pure carbolic acid to the interior of the wound in the last case,
the next which came under notice was more thoroughly treated,
the contused parts being well manipulated and squeezed, so
as to induce the liquid carbolic acid, which was introduced, to
penetrate into all the interstices of the wound. At a later period,
in order to permit cicatrisation, the crust was chpped away
around the margin, and a solution of sulphite of potash (5 grains
to the ounce) applied.
K
130 ASEPTIC SURGERY.
In future, the method of introducing strong carbolic acid
into wounds by means of a piece of lint soaked in the undi-
luted acid, held in dressing forceps, was adopted. The blood
clots were as far as possible removed.
In order to obtain a more substantial crust and one less
likely to be detached, in cases where there was too little blood,
a paste was made use of, composed of starch, moistened with
carbolic acid placed outside a piece of calico soaked in pure
acid, and applied next the wound. As a rule, however, there
is enough blood to form a substantial crust if several layers of
calico are used.
A great risk of putrefaction was all along experienced,
owing to the fact that the pure acid could not be made to
overlap the skin around the wound because of the excoriation
caused by it. This risk was especially great in the first
twenty-four hours, during which there was a profuse flow of
blood and serum. Hence attempts were made to obtain some
sort of dressing containing the acid in a more diluted form,
and the first-fruits of these attempts was the formation of
various pastes, of which the chief was long known as carbolic
putty. This consisted of a 1 in 5 solution of carbolic acid in
boiled linseed oil mixed with common whiting (CaC03), to
the consistence of a firm paste or putty. This was then spread
on a sheet of block tin, forming a layer of about a quarter of
an inch in thickness. A piece of lint dipped in 1-5 oily solu-
tion was retained permanently next the wound so as to prevent
its exposm-e during the changing of the dressings. The whole
dressing was firmly fixed down by means of a continuous series
of strips of plaster, which, however, were absent at the most
dependent part, so as to allow the escape of discharge, which
was received on a towel. After some time it was found better
to apply this putty between two layers of calico, and then the
block tin outside all.
The advantages of this dressing are : the tin applied out-
side prevents the escape of the carbolic acid, the acid in the
putty is just sufficiently diluted not to excoriate the skin, while
the paste serves as a reservoir for the acid during the interval
which elapses between the changing of the dressings, the dis-
charge, as it flows out beneath the putty, taking up only a
ITS DEVELOPMENT. 131
certain amount of the acid in its course. If necessary the
strength of the acid in the putty may be reduced.
Its disadvantages are that it is clumsy and inconvenient
to manipulate, and that it is very apt, when subjected to move-
ment, to crumble away, and thus become an uncertain dress-
ing. Attempts were therefore made to improve it, and recourse
was had to various forms of plasters. The first of these was the
lead 'plaster,^
The following is the mode in which this is prepared : —
Take of olive oil 12 parts by measure
„ ,, litharge (finely powdered) 12 parts by Aveight
„ „ beeswax 3 „ „ „
,, „ crystallised carbolic acid 2^ ,, ,, „
Heat half the oil'over a slow fire ; then add the litharge gradually,
stirring constantly till the mass becomes thick or a little stiff. Then
add the other half of the oil, stirring the mass as before, till it becomes
thick. Then add the wax gradually till the liquid again thickens.
Remove from the fire and add the acid, stirring briskly till thoroughly
mixed. Cover up close and set aside, and let the litharge settle, then
pour ofi" the fluid and spread on calico. The large quantity of litharge
in this mixture was introduced for the purpose of preventing the
melting of the plaster at the temperature of the body.
The wound was dressed with layers of lint soaked in car-
bolic oil, and this dressing was covered in all directions with
the plaster. This plaster was renewed daily.
As with the putty, so here, the deep dressing was apt to be-
come displaced, and therefore Mr. Lister used lead plaster as
the outermost layer of the deep dressing, in the hope that it
would adhere to the skin and prevent lifting of the edges of
the dressing. In order to prevent the outer layer of the
plaster from sticking to this inner portion, a piece of calico
moistened in the watery solution was interposed. But though
the plaster does very well for the outside layer, it does not do
for the permanent dressing, for it allows the watery solution
from the calico to soak through to the wound beneath. At the
same time this deep layer, not having formed a crust, is apt to
shift its place, and to leave the wound more or less exposed.
' Brit. .Vrd. JiniriKil. Octolicr ;>!, 1878.
K 2
J32 ASEPTIC SURGERY.
Mr. Lister accordingly tried other sorts of plaster, and at
length in shell lac he seemed to have found all that he wanted.
This lac mixes in any proportion with carbolic acid, and is more
or less fluid or tenacious, according to the quantity of acid
present. The shell lac parts but slowly with its acid, and thus
forms a good dressing. It is, however, very apt to stick, and
in order to prevent this Mr. Lister interposed a layer of gutta-
percha between it and the skin. The carbolic acid passes
through the gutta-percha with extreme readiness, while the
latter prevents the lac from sticking to the deeper parts.
Gutta-percha tissue, however, proved apt to crack, and then
the discharge got between it and the lac plaster, and thus
the fluid beneath it received but little carbolic acid. Hence
the same result happens with this cracked gutta-percha as when
protective extends to the edge of the dressing — viz., a deep
layer of the fluid is more or less protected from the action of
the acid, and putrefaction can spread inwards.
After several experiments he ultimately employed a solution
of gutta-percha in bisulphide of carbon to brush over the
surface of the lac plaster.
The following is the method of preparing the plaster : —
* Take of shell lac ...... 3 parts
„ „ crystallised carbolic acid ... 1 part
' Heat the lac with about one-third of the carbolic acid over a slow
fire til] the lac is completely melted, then remove from the fire and
add the remainder of the acid, and stir briskly till the ingredients ai-e
thoroughly mixed. Strain through muslin and pour into the
machine for spreading plaster, and when the liquid has thickened by
cooling to a degree sufficient, spread to the tliickness of one-fiftieth of
an inch. Afterwards brush the surface of the plaster with a solution
of gutta-percha in about 30 parts of bisulphide of carbon. When the
bisulphide has all evaporated the plaster may be piled in suitable
lengths in a tin box without adhering, or rolled up and kept in a
canister.'
For the permanent dressing in compound fracture adhe-
siveness is wanted, and this is obtained by rubbing off the
gutta-percha and brushing liquid carbolic acid over the surface.
At this time (1868) the necessity for protecting the healing
l)arts from the direct action of the carbolic acid was beginning
ITS DEVELOPMENT. 1^3
to be recognised, and Mr. Lister first speaks of the use of block
tin or sheet lead as a protective.
At the same time, having obtained a pmrer carbolic acid
soluble in water, he gives up the application of the pure acid
to the interior of the wound in compound fractures, and syringes
it out with a solution of 1-20 instead.
In the 'British Medical Journal' for March 19, 1870, a
description is given of the method then used. The wound was
in the first instance thoroughly syringed out with 1-20 carbolic
lotion. Then oil silk covered with a layer of dextrin was applied
iu one or two layers, and outside this the lac plaster. If much
discharge was expected lint or a towel was placed outside the lac
piaster in order to absorb the discharge. Where the dressing
was left undistui'bed for a week two layers of plaster were used.
Where a small piece of lac plaster was applied as a deep dressing,
and where consequently the gutta-percha was rubbed off to allow
the plaster to adhere to the skin, the gutta-percha was left at one
part so as to afford a channel for the escape of discharge.
In changing these dressings a solution of carbolic acid 1-20
was thrown over the wound by means of a syringe, as the dressing
was raised, and then a guard soaked in the lotion was applied.
In 1869 catgut ligatures were introduced.
The objections to the lac plaster are that the discharge
putrefies outside the plaster and irritates the skin, that the lac
keeps the surface beneath it moist with what is really a film of
watery solution of carbolic acid, and this again makes its way
under the protective and irritates the woimd.
Very shortly after the use of the aseptic method in the
treatment of compound fractures it was a})plied to abscesses.
The first publication on this subject appeared in the
'Lancet' for July 27, 1867. The method of opening the
abscess and of changing the dressings employed with the
means at that time at disposal are very important with
reference to the question of operating and dressing without a
s})iay. A piece of rag dipped in 1-5 carl)olic oil is laid on the
skin where the incision is to be made. The lower edge of this
rag being raised, a knife dipped in the oil is at once plunged
into the abscess, and the rag immediately dropped over the
orifice through which the pus is pressed out. A piece of lint
134 ASEPTIC SURGERY.
soaked in the oily solution is then introduced into the opening
in order to stop bleeding and to prevent it from closing. This
is done by slipping the strip of lint under the antiseptic rag.
With regard to the dressing, the putty is here described and
used outside a deep dressing of carbolic oiled lint, a layer of
calico being interposed between the putty and the deep dressing
to prevent them from sticking together. The putty is changed
once in twenty-four hours, or oftener if necessary. In doing so
a rag dipped in the oily solution is placed over the wound or
the deep dressing the instant the old putty is removed. If a
plug of lint has been introduced in the first instance it is after
a time (two or three days) withdrawn by pushing oiled forceps
under the piece of oiled rag, seizing hold of the plug and
pulling it out, the oiled rag being pressed thoroughly around
the forceps. If a probe is introduced it must be oiled and then
slipped in between the folds of the oiled rag. As the various
means described under compound fracture were introduced they
were applied to abscesses on the principles already described.
The first example of efficient aseptic treatment in the case
of wounds published by Mr. Lister will be found in ' The British
Medical Journal ' for October .31, 1868,^ The case narrated is
one of operation for badly united Pott's fracture.
' On the 11th inst. (April, 1868), the man being under the
influence of chloroform, I made a curved incision behind and
below the prominent end of the tibia, a solution of carbolic
acid in four parts of olive oil being dropped into the wound
during the progress of the operation. I detached the soft
parts from the bone sufficiently to enable me to insinuate
behind the callus one blade of a pair of cutting pliers smeared
with the same oil, and then having placed pieces of lint soaked
with the oil around the blades of the pliers, so as to prevent
the chance of septic air entering the joint when the bone gave
way, divided the callus, and at once covered the wound with the
antiseptic lint. . . . The wounds were then dressed with a
weak oily solution of carbolic acid, and covered with the anti-
septic (lead) plaster. Fresh plaster was applied daily.'
I need not repeat the various modifications in the treatment
' Reports published during the same year by Drs. Heron and Malloch will
be found in the Glasgow Medical Jonrnal.
ITS DEVELOPMENT. 135
of wounds, as they are similar to those just described under
compound fractures.
In the 'British Medical Journal' for January, 1871, JMr.
Lister first mentions the gauze dressings, and also refers to the
use of oakum. The spray is also tried. In August, 1871,
this method has been established, the present protective was com-
pleted, and macintosh was substituted for gutta-percha tissue
below the outer layer of the gauze. The drainage tube is first
mentioned in August, 1871, in the treatment of wounds,
though it had been used for a short time previously in the case
of abscesses. At that time the piece of gauze next the wound
was not wet. It was some two or three years later that the
necessity for wetting the deep layer was recognised, and since
that time the results have been much more constant. With
the introduction of the steam spray, of the elastic bandage,
of the improved gauze, &c., there has been a marked improve-
ment in results, and the avoidance of putrefaction, in cases
where the wound is made by the surgeon, is now reckoned on
as a matter of course.
130 ASEPTIC SURGERY.
CHAPTER VI r.
ASEPTIC SURGERY — {concluded).
Other methods of carrying out AsejDtic Surgery. Substitutes for carbolic
acid: Salicylic acid: Thymol: Acetate of Alumina: Eucalyjrtiis oil.
Aseptic surgery by filtration of the air. Subcutaneous surgery.
Such are the essential details of aseptic surgery as introduced
and i^ractised by Mr. Lister. The disadvantages arising from
the irritating and poisonous qualities of carbolic acid have led
some to seek other antiseptics as substitutes for carbolic acid.
These attempts have not as yet, however, succeeded in producing
any substance possessing so many advantages as that acid.
The most successful substitute up till quite recently was
salicylic acid, which is used on exactly the same principles,
but not with the same constant aseptic results.
The use of salicylic acid was first advocated by Professor
Thiersch, of Leipzig, and the following is a short abstract of
his method of using it.
Salicylic acid is chemically nearly related to carbolic acid.
Its formula is C^HgOy, differing therefore from that of carbolic
acid in containing in addition the atoms of carbonic anhy-
dride. (The formula of carbolic acid is CgHgO.) Salicylic
acid is not poisonous, but it affects the hands in the same
way as carbolic acid. It is absorbed, and may be found in the
urine of patients whose wounds are dressed with it.
A lotion of salicylic acid is employed. This is a saturated
solution of the acid in water at the ordinary temperature, and
its strength is about 1 part of salicylic acid to 300 parts of
water.
Two materials are used as dressings — viz., salicylic wool and
saHcylic jute.
TREATMENT BY SALICYLIC ACID. ]37
Salicylic wool is cotton wool impregnated with salicylic acid
in the proportions of 3 and 10 per cent, by weight.
The 3 per cent, wool is made by dissolving 750 grammes of
salicylic acid in 7,500 grammes of spirit (83 sp. gr.). This
solution is then diluted with 150 litres of water at the temper-
ature of 70°-80° C. 25 kilogrammes of pure cotton wool are
saturated with this mixture.
The 10 per cent, wool is obtained by dissolving one kilo-
gramme of salicylic acid in 10,000 grammes of spirit (83 sp. gr.),
the solution being then mixed with 60 litres of water. Ten
kilogrammes of pure cotton wool are soaked in this solution.
This soaking is best done in a large wooden vat, in which
the layers of cotton wool have plenty of room. It is best to
place only small quantities of wool (two to three kilogrammes)
in this vat at a time in order to get an equal distribution of
the acid. Thin layers of cotton wool are introduced into the
salicylic solution under light pressure, fresh layers being added
only when the former have been thoroughly soaked. When
the whole quantity has been introduced the mass is turned
over, so that the undermost layer becomes the uppermost, and
then it is left for about ten minutes, so as to have equable
distribution of the fluid. The wool is then taken from the vat
and spread out in layers. On cooling, the acid crystallises out,
and the layers are made up into small parcels, not exceeding
two to three kilogrammes each. After twelve hours this wool is
spread out to dry in a moderately warm place. It should not be
hung up, lest the acid should become unequally distributed.
The 10 per cent, wool is coloured with carmine for the sake
of distinction.
It is important to note that Thiersch, in speaking of 3 per
cent, and 10 per cent, wool, means wool soaked in the solutions
of the strength described. The wool does not contain that per
centage of salicylic acid.
This cotton wool does not absorb fluids readily, and therefore
Thiersch now uses jute. This is made from the bark of various
species of Corchorus grown in Bengal, and is cheaper than
cotton wool, and at the same time more absorlient. It is used of
two strengths — 3 and 10 per cent, prepared in the same way
as the salicylic wool.
138 ASEPTIC SURGERY.
Grlycerine is added to the solution in order to prevent the
crystals of salicylic acid from falling out, because they are apt
to produce violent sneezing, coughing, &c.
In order to obtain the 3 per cent, jute 2,500gTammes of jute are put
into a sohition of 75 grammes of salicylic acid, in 500 grammes of
glycerine and 4,500 grammes of water at 70°-80° C.
In the glycerine jute the acid is more equally distributed
than in the cotton wool. In the case of the latter the cotton
is frequently so imperfectly charged that it is necessary to place
a layer of 10 per cent, cotton next the wound, and then outside
this the 3 per cent. wool. In the case of the glycerine jute a
4 per cent, material is sufficient for the whole dressing.
As to the spray Thiersch does not care whether it is 1-50
carbolic acid or 1-300 salicylic acid. Carbolic acid is to be
jjreferred, because it causes less coughing and sneezing, and it
does not adhere to the clothes.
Salicylic acid is best in some cases, as it irritates the wound
less than the carbolic.
For disinfecting the hands and skin, carbolic acid or salicylic
acid may be used, but for the instruments carbolic acid must
be employed, because the steel becomes oxidised in a solution
of salicylic acid.
The sponges are washed in carbolic acid.
No protective is required, because the salicylic acid is but
little irritating.
Macintosh is also unnecessary.
In order to enable the dressing to peel off and to let the
discharge get away more easily a layer of gutta-percha tissue
or of oiled silk riddled with holes and covered with a piece of
gauze is applied next the wound.
This treatment may be illustrated by a case of amputation.
The patient having been chloroformed and Esmarch's elastic
bandage applied, the part is shaved, washed with soap and
water, spirit and turpentine oil, and then with salicylic acid
lotion, or with the 1—20 carbolic acid solution. It is also
scrubbed with a nail-brush for a few minutes (quite unneces-
sary). The operation is carried out with the usual aseptic
precautions. After arresting the haemorrhage the wound is
TREATMENT BY ^SALICYLIC ACID. 139
closed with deep and superficial stitches. A drainage tube is
then introduced into each angle, and the wound is washed
out with salicylic acid solution till the fluid which comes out
is clear (unnecessary). Three finger-breadths of perforated
gutta-percha and of carbolic gauze is then applied ; over this
one finger's thickness of the strong salicylic wool, and outside
this two fingers' thickness of the weak wool. The whole is
then fastened on with a bandage.
If the patient complains of pain the dressing is changed
and the wound examined. If not, it is left till the eighth or
tenth day, when it is changed, in order to remove the drain-
age tube. If any discharge comes through in the first instance
fresh wool is put outside the dressing. The second dressing
is left till healing is complete.
Large compound fractures are treated at first by irrigation
with salicylic acid. In order to protect the skin from maceration
by the fluid it is from time to time rubbed with palm oil.
After all risk of abscess formation has passed off and the wound
is granulating well, one may apply dry salicylic dressing as
before described.
Where there is a tendency to inflammation, more especially
where there is imperfect drainage with progressive abscess
formation, wet salicylic dressing should be applied. This is
ordinary salicylic dressing, which is from time to time soaked
with salicylic lotion.
Thymol as an antiseptic application to wounds was intro-
duced some years ago by Eanke of Halle, and was much lauded
on account of its non-poisonous and non-irritating qualities.
The thymol gauze was made on the same principles as the
carbolic gauze, spermaceti being, however, employed. A thymol
solution of the strength of 1-1000 is made by the addition of
alcohol and glycerine.
This antiseptic has not answered the expectations entertained
at first. It does not prevent putrefaction, and has been justly
abandoned in aseptic work.
Acetate of alumina has been lately used by Maas. He
applies lint dipped in the solution (2^ per cent.) to the wounds,
140 ASEPTIC SURGERY.
and covers this with macintosh. The strength of the spray is
also 2^ per cent.
He says that this is a powerful antiseptic, and that with it
he gets typical aseptic results. The substance is unirritating,
and very few dressings are required.
Eucalyptus oil has recently been strongly advocated by Dr.
Schulz of Bonn.' Its antiseptic properties were shown by
Bucholtz in his paper on antiseptics. He found that it was
three times as strong as carbolic acid, for while carbolic acid
prevented putrefaction when present in the proportion of 1 in
200 parts, the eucalyi^tus oil only required to be present in
the proportion of 1 to 666*6 parts to produce the same effect.
Siegen also showed that eucalyptus oil prevents putrefaction
and alcoholic fermentation better than carbolic acid. He found
that blood to which ^ per cent, of eucalyptus oil had been
added was quite odourless ten days later. Eing states further
that it hinders the passage of white corpuscles out of the vessels,
and that therefore, on Cohnheim's theory, it is an agent capable
of arresting suppuration.
With regard to its usefulness, its smell is more pleasant
than that of carbolic acid. It dissolves readily in alcohol or
in oil, and mixes perfectly with pure paraffin.
Schulz also states from Siegen's experiments and from his
own that the eucalyptus oil is not poisonous. The tree from
which the oil is obtained grows in large numbers in Australia,
and the oil can be obtained in large quantities and very cheap.
Schulz recommends that for the spray the glass bottle
should be filled with the pure oil or with oil dissolved in alcohol.
The steam would then pick this up and make an emulsion.
As a lotion it might be used in the form of an emulsion.
Schulz proposes that the wounds should be dressed with
lint saturated with a 10 per cent, solution of eucalyptus or olive
oil. Outside this, or instead of it, may be used Lister's gauze
dressing containing eucalyptus oil instead of carbolic acid.
A gauze which contains even 50 per cent, of eucalyptus oil may
be made with paraffin. Dr. Schulz has not himself, however,
used this method.
' Ciidnilhlultfiir Chvrimjit', Jannury 24, 1880.
USE OF COTTON WOOL. 141
Quite recently .Mi-. Lister has been making an extensive
trial of eucalyptus oil in the treatment of wounds. A gauze
has been prepared similar to the ordinary gauze, but containing
eucalyptus oil instead of carbolic acid. Dammar has also been
substituted for the ordinary resin. So far this has proved very
satisfactory. It seems to be trustworthy as an antiseptic, and
can be used under circumstances where carbolic acid is apt
to cause irritation, as in dressings on the scrotum, or in patients
whose skins are liable to be irritated by carbolic acid. Being
non-poisonous, it may also be substituted for carbolic acid in
cases where constitutional effects are apt to follow the absorption
of the latter.
It has also been employed as an ointment in the proportion
of 1 part by measure of the oil to 4 parts by weight of the same
base as is used for the boracic and salicyHc ointments (p. Q5\
This ointment is employed in the cases for which boracic and
salicylic ointments have up to the present been used, and it
possesses the advantage over the latter in that the oil not only
renders the discharge pure as it passes over it, but also on
account of its volatility bathes the parts in an antiseptic
vapour. Hence it will probably be especially useful in the
treatment of burns (see p. 116). Its non-poisonous qualities are
also a great point. As yet no experiments have been made with
the view of substituting it for carbolic acid in the lotions used
in the spray, in washing wounds, purifying instruments, &c.,
and indeed the whole matter is only for the present under trial.
So far we have been considering modes of preventing
putrefaction in wounds based on the fact that the septic particles
in the air and on surrounding objects may be deprived of their
power of causing fermentation by contact with some suitable
chemical substance. But we also saw in the preliminary
considerations that it sufficed for the avoidance of fermentation
in flasks to keep the dust out mechanically, as, for instance
by means of cotton wool. This fact was made use of by Mr.
Lister some years ago in the following manner. I may quote
his remarks, which are given in a foot-note to his article on
Amputations in Holmes' ' Surgery,' vol. v. p. 619, published in
1871.
142 ASEPTIC SURGERY.
' Amonar recent contributions of foct to the elucidation of
this question (the germ theory) may be mentioned Professor
Tyndall's simple but beautiful proof of the existence of organic
particles of dust of excessive minuteness in the air by means
of a condensed beam of light, and the equally clear ocular
demonstration afforded by the same method, that even the
finest particles are capable of being removed from the air by
causes which Pasteur, in some of his experiments, inferred must
clear it of suspended organisms, such as the action of gravity
and filtration by cotton wool. The fact last named seemed to
promise valuable results in antiseptic surgery, and experiments
made with this view have afforded further evidence in favour
of the germ theory which it may be well to mention here. I
found that if cotton wool impregnated with either chlorine or
sulphurous acid gas or with the vapour of benzine or carbolic
acid, was placed upon a wound or granulating sore, after
washing the surface with a solution containing the same agent,
although the volatile antiseptic left the cotton in about a day,
the blood or pus still effused beneath the cotton remained free
from putrefaction for an indefinite time, provided that the
discharge was not sufficiently copious to soak through the
cotton and appear at the surface, in which case the meshes
between the fibres affording ample space for microscopic
organisms to develop in, putrefaction spread within a few
hours throughout the moistened part of the mass. This cir-
cumstance greatly interfered with the practical utility of the
dressing, and it has since been superseded by the antiseptic
gauze to be described in the text, but the facts seem to me
important with regard to the germ theory. The cotton wool,
though it loses all chemical antiseptic virtue in a day, yet will
keep out putrefaction for a month or more. It cannot possibly
keep out any atmospheric gas, which is necessarily diffused
freely between its fibres, and gets in for the same reason that
the volatile antiseptic gets out. That which it does exclude
can only be suspended particles of dust. It follows, therefore,
as a matter of certainty, that the cause of putrefaction through
atmospheric influence of blood or pus, oi-, in other words, such
materials as the surgeon has to deal with in treating wounds.
USH OF COTTON WOOL. 143
are not the atmospheric gases, but dust, and the fact that this
dust is deprived of its putrefactive energy by agents which are
chemically so unlike as chlorine, sulphurous acid, benzine, and
carbolic acid, but which agree in having a common hostility to
animal or vegetable life (I used benzine because I knew that
the entomologist employs its vapour to kill insects), this fact
confirms the view that the putrefactive particles are really
organisms. I commend these simple experiments with cotton
wool to the candid judgment of the reader, because, whatever
may be thought of their bearing upon the allied subject of
spontaneous generation, they must be allowed to afford absolute
demonstration of the truth which is the foundation of the anti-
septic system, viz,, that the putrefaction of blood or pus under
atmospheric influences is caused not by the gases of the air,
but by suspended particles, which can be deprived entirely of
their septic energy by the vapour of an agent like carbolic acid.'
It will thus be seen, that what Mr. Lister used here was
not an antiseptic application but an aseptic one, and that the
only mode in which this dressing acted was by mechanically
preventing the particles from reaching the wound. For the
reasons quoted, this method has not been turned to practical
account, though, as we have seen, it is still used in cases of
gangi-ene in order to protect the weak ^Jarts from all sources of
irritation.
Mr. Barker, assistant surgeon to University College Hospital,
has tried a similar method in one or two cases. He piuified
cotton wool by heat, and applied between it and the woimd a
layer of lint dipped in carbolic oil. This method, however,
seems to be impracticable, for after the wool has been heated,
but before it is applied, dust would very probably gain access to
it unless very complicated precautions were taken. I believe
that if ])ure cotton wool is used Mr. Lister's method is the only
practicable one.
I have mentioned these experiments more as confirming
the flask experiments described before than for the purpose of
recommending the method for adoption. I believe that tho-
roughly satisfactory and indeed the best results maybe obtained
by the use of suitable chemical means.
144 ASEPTIC SURGERY.
Subcutaneous surgery is another way in which the aseptic
principle may be carried out. Here the wound is made under
the skin and away from the air dust altogether. This method
will be better understood when we come to trace the history
of antiseptic surgery.
PARTICLES WHICH CAUSE FERMENTATION. 145
CHAPTER VIII.
THEORIES OF SPONTANEOUS GENERATION, HETEROGENESIS
AND ABIOGENESIS.
Principles on wliich other methods of antiseptic surgery act. Organisms are
always present in fermenting liquids : their significance. Theory of the
origin of organisms independently of a parent. Theories of Needham and
Buffon : Needham's proofs. Spallaazani's experiments: Needham's objec-
tions : Spallanzani"s replies. Schulze's experiments. Schwann — Schroeder
and Dusch — Schroeder — Doctrine of Heterogenesis. Pouchet's work : his
method of testing the matter : proofs that the source of the organisms in
infusions is neither the air, water, nor the putrescible substances : modes
of repeating Schulze's and Schwann's experiments : examination of dust.
Criticism of his results. Pasteur's experiments : results with ordinary
fluids : introduction of dust into sterilised fluids : results with milk and
alkaline fluids : the cause in the air which gives rise to the growth of
organisms is particulate : Pasteur "s cultivating fluid : estimate of Pasteur's
work. Poachefs reply : New experiments — Criticism of these.
8uCH are the methods by which that form of antiseptic surgery
which aims at the total exclusion of septic ferments may be
best earned out. But ' Antiseptic Surgery ' in its broad sense
includes another class of methods of treatment acting on a
totally distinct principle, and interfering more or less perfectly
with the occurrence of fermentations. These all act on the
principle of rendering inert the causes of jjutrefaction after
their entrance into the luownd, of offering obstacles, more or less
co')nplete to the fermentation ivhich these pai^ticles would other-
luise occasion. In order to understand these methods, to see
on what ja-inciples they act, to decide which are the best, and
to carry them out with the greatest success, it is necessary to
take up our discussion of the causes of putrefaction at the point
wliich we have already reached, and to consider what is the
nature of the particles which we fotind to be ihe causes of
L
146 SPONTANEOUS GENERATION.
fermentative changes, and how it is tlmt they bring about these
changes.
As is well known, micro-organisms of some form or other
(bacteria, toruUie, &c.)are always present in fermenting liquids,
and the view which is now almost universally held by scientific
men is that these bodies are the initiators of the chemical
change.
We have nlready seen that fermentation occurs only after
the access of particles from the outer world, and it is asserted
by the supporters of the germ theory of fermentative changes,
that these particles aire organisms or their spores, and that it is
by the growth of these organisms in the fermentescible material
that the latter undergoes alteration.
Soriie, however, assert that these organisms are only acci-
dental accompaniments of the process of fermentation ; in fact
a few still maintain that they arise in fermenting substances
from agglomeration of the molecules of that material, that in
feet they are generated anew and are not necessarily derived
from a parent. It is therefore necessary for us, before discuss-
ing the germ theory of fermentation, to consider what are the
real focts with regard to this matter of abiogenesis.
The first views of which we must take notice, as being the
first founded on experiment and observation apart from mere
philosophical speculation, are those of Needham and Buffon,
published in the middle of the eighteenth century.' Needham's
' It may be of interest to quote Needham 's own words somewhat in detail.
Referring to Spallanzani's criticisms of his viOT:]<i{Xnurvlles liecherches sitr Ics
litres wicroscojnqiies, by Spallanzani, translated by M. I'Abbe Regley, 1769),
he savs (vol. i. p. 142) : ' II (Spallanzani) sait trrs-bien par toute la tenenr de
mes observations raicroscopiqnes que je ne donne aucune autre puissance h la
mati^re que celle qui produit la pure vitalite denuee de toule sensation, et qui
derive, comiue son existence primitive, de la seule Divinite ; que cette
vitalite est un compose materiel de la force resistante et de la force expansive,
dont les premiers principes ont ete donnes a la matiere par le Crc'ateur au
moment de la creation : que tout corps, ou partie organisee, est une proces-
sion ou prolongation d'un corps organise, soit vegetal ou animal, qui doit
nrcessairement preexister, et dont la soucheiDrimitive sort immediatement des
mains de Dieu ; que cette procession ou prolongation insensible, que doit
donner ce germe nouveau, dont la petitesse est indetinie, pour se conformer A,
toutes les circonstances possibles, se fait moyennant une espece de reduction
dirigee par les forces plastiques, et une concentration des parties specitiqucs,
(lui tendent, en les attenuant, vers nn point determine ou un certain foyer
commun, de mrine u ]ieu ]ir(\s que Tccil est au monde visible, un centre ou les
NEEDHAM. 147
theory was, that there is in matter a force charged with the
formation and government of the organic world, which force he
rayons viennent s'arranger de toutes parts, sans confusion, dans le mcme ordre
qu'ils re9oivent de I'harmonie preetablie de I'univers ; que quant aux premiers
principes de cette vitalite purement materielle, il y a une mati^re indubitable-
meut demontree par des experiences constant es, trfe-attenuee, tr^s-exaltee ,
etheree selon Newton, electrique selon les idees presentes, tres-elastique par sa
nature intime, toujours prete iidonner lebranle a la mati^re brute et rusistante,
et qui penetre substantiellement la masse enti^re ; que par consequent ces
deux especes de mati^re, melees dans toutes les proportions possibles, peuvent
fournir les temperaments necessaires pour tout degre de vitalite quelconque, et
pour tons les grands phenomenes on changements physiques de I'univers en
partant d'un seul principe ; que cette vitalite, n'etant autre chose qu'un esprit
tres-subtil et trfes-actif, agissant dans une matiere brute, tenace et ductile,
pour former, selon les forces specitiques de chaque corps vital, un nouveau
systeme organise, est tr^s-dilferente, selon mes idees, du principe seiisitif, qui
ne pent etre compose, et encore plus distinguee du principe intellectuel et
sptrituel, I'ame de rhomme.'
Further on (p. 150) he reiterates his view that these beings are distinct
from the higher classes of animals which possess sensation. ' En general,
toute substance quelconque, animale ou veg6tale, se decompose, selon moi, en
etres que j'appelle Hte?/.a; pour les distinguer des animaux parfaits a qui la
Divinite a ajoute par surcroit les puissances purement sensitives, ou sensi-
tives-intellectuelles.'
Again (p. 172), ' L'auteur (Spallanzani) croit que j'ai parle de la force
ordinaire vegetante des plantcs, par laquelle elles develop25ent en feuilles, en
branches et en racines. II n'est rien de tout cela. Quand il s'agit de la pro-
duction de ces corps organiques, je considere an contraire la plaute dans un
etat de corruption comma jilante : car c'est alors qu'elle perd absolument
sa forme primitive et, quapres avoir ete depouillee de ses sels, de ses huiles,
et des autres principes constitutifs, ce qui reste devient une matiere gela-
tineuse et loute tilamenteuse qui vegete par elle-meme en branches vitales et
se partage en corps ronds animes ou pousse au-dehors des globules mouvants.'
' Voila en jjeu de mots le vrai tableau, voilii le raisonnement de M. de
BiifTon et le mien. II y a certainement un principe de vitalite materiel dis-
tingue du principe sensitif, seul constitutif de la stricte animalite, qui se dis-
pose organ iquement, et qui, subordonne aux lois generales etablies jDar la
Divinite, vegete dans les corps animaux qu'il forme conime dans les vegetaux,
en les animant ^ la fa(;on ordinaire ' (p. 166).
' Ce principe de vitalite est le seul principe d^conomie et d'action dans lea
vegetaux, et dans une certaine classe de ces Ctrcs qui, paraissant scnsitifs sans
Fetrc, servent i\ lier ensemble le vegetal et I'animal sensitif ' (p. 166).
'Mais j'ai toujours reconnu comme necessaire pour completer le vrai
animal, qui doit etre sensitif, un principe de sensation, une time qui n'est pas
coniposee comme le systeme organique, et qui, quoique aneantie avec le corps
selon le bon plaisir de son cn'atcm-, est ni'anmoius superieure ^ la vitality, et
hors de toutes les puissances du la matiere la plus exaltee.'
Bullon {IlisUmr Xaturcllc, vol. ii. p. 420, 171'.)) says : ' Tous les aniruaux
L 2
148 SPONTANEOUS GENERATION.
calls force vegetatrice. He imagines that this force, by setting
into motion all the particles of matter, excites in some of them
a sort of vitality distinct from sensation, and produced by the
union of two other forces, which he terms fo7xe resistance and
force expansive.
The proofs on which Needham bases his views as to the
spontaneous origin of these minute organisms are of three
distinct kinds.
The first discussing the different phenomena furnished by
different infusions, more especially the enormous variety of
forms arising in them ; and the second alluding to the behaviour
of infusions after being subjected to heat, dependent as these
arguments are on microscopical examination, need not be con-
sidered here, because the construction of the microscope was at
that time so imperfect as to make it of little or no use for such
observations.
The third, and indeed the only experiments which require
to be noticed, are those in which infusions, contained in vessels
hermetically sealed, are subjected to the action of heat for a
prolonged period. In infusions treated in this way by Need-
se nourrissent de vegetaux ou d'autres animaux, qui se nourrissent eux-memes
de vegetaux ; il y a done dans la nature une mati^re commune aux uns et aux
autres qui sert a la nutrition et au developpement de tout ce qui vit ou veg^te;
cette matiere ne peut operer la nutrition et le developpement qu'en s'assimi-
lant k chaque partie du corps de I'animal ou du vegetal, et en penetrant in-
timement la forme de ces parties, que j'ai appelee le moule interieur. Lorsque
cette matiere nutritive est plus abondantequ'il ne faut pour nourrir et develop-
per le corps animal ou vegetal, elle est renvoyee de toutes les parties du corps
dans un ou dans plusieurs reservoirs sous la forme d'une liqueur ; cette liqueur
contient toutes les molecules analogues au corps de I'animal, et par consequent
tout ce qui est necessaire a la reproduction d'un petit etre enti6rement sem-
blable au premier. Ordinairement cette matiere nutritive ne devient sura-
bondante, dans le plus grand nombre des especes d'animaux, que quand le
corps a pris la plus grande partie de son accroissement, et c'est par cette raison
que les animaux ne sont en etat d'engendrer que dans ce temps.
' Lorsque cette matiere nutritive et productive, qui est universellement
repandue, a passe par le moule interieur de I'animal ou du vegetal, et qn'elle
trouve une matrice convenablc, elle produit un animal ou un vegetal de meme
espece ; mais lorsqu'elle ne se trouve pas dans une matrice convenable, elle
produit des etres organises difl'^rents des animaux et des vegetaux, comme les
corps mouvans et vegetants (jue Ton voit dans les liqueurs seminales des ani-
maux, dans les infusions des germes des plant es, kc'
SPALLANZAIK. 149
ham and boiled for many minutes organisms developed very
readily.
Spallan5^ani ' repeated these experiments, and he found that
though some infusions could be sterilised after boiling for a
short time, yet it was necessary to keep others at the boiling
temperature for an hour or more before they would remain
permanently sterile. Spallanzani's method was to heat his
flasks, then to pom- in the liquid, hermetically seal the flask,
and place it in a water bath. The error in this method is
probably that the impure fluid when poured into the flask,
soiled the neck which he had previously purified by heat.
To these experiments Needham objected that Spallanzani
had much enfeebled or perhaps destroyed the force vegetatrice
of the infusions by keeping them exposed to the action of heat
for so long a period of time as an hour.
This objection was at once met by Spallanzani, who showed
that organisms rapidly developed in these same infusions, if
they were left exposed to the air after this prolonged boiling ;
and he truly says that, if the organisms only come from the
fluid, and if the power which this possesses of generating these
beings is destroyed by heat, they would remain absent whether
the flasks were open or shut. He even went further and heated
the vegetables very strongly before infusing them, but even
in this case organisms developed in the fluids so prepared.
Needham, however, said that the small quantity of air re-
maining in the flasks was completely altered by the exhalations
from the fluid and by the heat of the fire, and that thus the
force vegetatrice could not act. This objection cannot be
said to have been in any way met by Spallanzani. In some
cases, indeed, he succeeded in preventing the appearance of
organisms by boiling the fluid from a half to two minutes, but in
many cases minute organisms appeared. In order to prevent
their occurrence in all instances, it was necessary to prolong
the heat for at least three-quarters of an hour.
As an answer to Needham's last objection the experiments
of Schulze ^ form a most important step in advance. The
' Opvsciiles de Physiqve animale et vegetale ; traduits par Jean Senebier,
Geneve, 1777.
* See translation in Microgcnpical Jmirnal, 1841.
150
SPONTANEOUS GENERATION.
following was the problem which he proposed and the method
adopted to solve it.
Query : ' If the access of atmospheric air, light, and heat
to substances in flasks included of itself all the conditions for
the primary formation of animal or vegetable organisms ? The
difficulties to be overcome consist in the necessity of being
assured first, that at the beginning of the experiments there
was no animal germ capable of development present in the
infusion, and secondly, that the air admitted contained nothing
of the kind.'
His method of procedure is described by himself as follows : —
' I filled a glass flask half full of distilled water, in which I mixed
vai'ious animal aud vegetable substances. I then closed it with a
Fif4. 58.— Schulze's method of demonstrating that organisms are
DERIVED FRO.Vr THE AIR AND DO NOT ORIGINATE SPONTANEOUSLY
IN LIQUIDS.
good cork, through which I passed two glass tubes, bent .it right
angles, the whole being air-tight. It was next placed in a sand-bath
and heated vintil the water boiled violently, and thus all parts had
reached the temperature of 212° F.
' While the watery vapour was escaping by the glass tubes I
fastened at each end an apparatus which chemists employ for collect-
ing carbonic acid ; that to the left was filled with concentrated sul-
phuric acid, and the other with a solution of potash. By means of
the boiling heat everything living and all germs in the flask or in
the tubes Avere destroyed, and all access was cut off by the sulphuric
acid on the one side and by the potash on the othei-. I placed this
easily moved apparatus before my window, where it was exposed to
the action of light, and also, as I performed my experiments during
SCHULZE. 151
the summer, to that of heat. At the same time I placed near it an
open vessel with the same substances that had been introduced into
the flask, and also after having subjected them to the boiling tempera-
ture. In order now to I'enew constantly the air within the flask, I
sucked with my mouth several times a day the open end of the
apparatus filled with solution of potash ; by which process the air
entered my mouth from the flask through the caustic liquid, and the
atmospheric air entered the flask from without through the sulphuric
acid (Fig. 58). The air was of course not at all altered in its com-
position by passing through the sulphuric acid in the flask, but if
sufficient time was allowed for the passage, all the portions of living
matter or of matter capable of becoming animated, were taken up by
the acid and destroyed. From May 28 till the beginning of August
I continued uninterruptedly the renewal of the air in the flask,
without being able, by the aid of the mici-oscope (magnifying glass ?),
to perceive any living animal or vegetable substance, although during
the whole of the time I made my observations almost daily on the
edge of the liquid ; and when at last I separated the dififerent parts
of the apparatus I could not find in the whole liquid the slightest
trace of infusoria, of confervse, or of mould. But all the three pre-
sented themselves in great abundance a few days after I had left the
flask standing open. The vessel which I placed near the apparatus
contained on the following day vibriones and monads, to which
were soon added larger Polygastric Infusoria, and afterwards Eotatoria.'
By these experiments the fears entertained by Needham as
to an alteration in the air contained in the flask being the cause
of the sterility of the infusion, were completely set at rest ;
for here air, which had not been subjected to heat, and which
was constantly changed, was present in the vessel in which no
development occurred, while the second open vessel showed that
the power of the liquid to nourish organisms had not been lost
by boiling. It was therefore clear that in this instance the
organisms which grew in the outer vessel came in some way
or other from ])articles in the atmos})here, which could be
destroyed by sulphuric acid. Whether or not both modes of
origin might not exist, and whether the bodies falling into
the fluid from the atmosphere were organisms or their spores,
or merely albuminous matters which gave rise to organisms,
was as yet in no way determined.
And the results of the experiments of Schwann, mentioned
]52 SPONTANEOUS GENERATION.
before, leave us in the same position. In his case the heating
of the air was substituted for Schulze's method of passing it
through a chemical substance, but no further evidence was
obtained. Advance was no doubt made by his results in that
the objection which might have been urged by some against
Schulze's experiments, viz., that particles of the sulphuric acid
were carried over with the air, or that the air was in some way
or other altered, are entirely removed,' while at the same time
it was then known that heating air joroduced no alteration in
the gases of the air. Schwann himself explained his results
by supposing that the spores of infusoria and other smaller
organisms are present in air, and are destroyed by heat ; and he
held that putrefaction and other fermentative changes are
brought about by these organisms abstracting materials for
their nutrition from the fluids in which they grow, and leaving
the compounds thus broken up to form new combinations.
One most important fact he does mention, viz., that blood
can be received into and preserved in a flask with certain pre-
cautions, without the development in it of any form of life.
Further evidence with regard to boiled substances was
brought forward by Schroeder and Dusch, and later by Schroeder
alone. Their method of experimentation by filtration of the
air through cotton wool, and their results, have been already
referred to (p. 12, et seq.), and it will be sufficient to add here
that in those cases where putrefaction occurred, organisms were
present, while in the flasks, in which no change took place,
organisms were absent. By their method, meat, meat infusion,
and malt were preserved after boiling without any appearance
of organisms.
Difficulties were experienced with milk and yolk of egg, but
these were finally overcome either by heating them to the
temperature of 130° C, or by prolonged heat at 100° C. These
experiments are of the greatest importance, as with the method
' This objection that the air is altered in passing through sulphuric acid is
not urged by Pouchet, who indeed states that no alteration occurs, and that
organisms can develop as readily when such air is admitted as in presence of
ordinary air. Schulze's experiment also proves that the barrenness of the
liquid was not due to the entrance of sulphuric acid into it, for the liquid
became full of life after having been exposed for a few days to ordinary air.
POUCHET. 153
employed no objections can be raised as to any alteration in
composition of the air.
When, then, we look at Needham's two objections, which
have been urged against experiments with boiled fluids, and
when we compare with them the answers furnished by all
observers, but more especially by Spallanzani to the first, and the
progressively strong replies to the second by Schulze, Schwann,
and Schroeder and Dusch, we must, I think, come to the con-
clusion that they have been completely met. Hence in order
to retain the theory of spontaneous generation it became neces-
sary for the heterogenists to change their ground. They had
to admit that there were present in the air and on surrounding
objects particles (not necessarily bacteria or their germs, though
very probably so) which, falling on suitable soil, gave rise to the
development of bacteria ; but they still held that under certain
circumstances heterogenesis may also occur, though possibly
more rarely than propagation from a parent.
They attempted to support this view in two ways : firstly,
by denying the accuracy of the former experiments, by pointing
out that they do not always succeed, and that organisms develop
in some materials, even after prolonged exposure to a high tem-
perature ; and secondly, by reference to the results of attempts to
preserve unboiled fluids and tissues.
In 1859 there appeared the work of one of the most ardent
supporters of the theory of spontaneous generation — Pouchet —
and it is necessary for us to examine his views and facts some-
what in detail.'
Pouchet does not look on these organisms as originating
from dead matter through the action of some mysterious force,
as has been since advanced by some heterogenists. Their sources
are, according to him : ' Des particules organiques, debris des
anciennes generations d'animaux et de plantes, qui se trouvent
combinees aux parties constituantes des mineraux. Selon cette
doctrine ce ne sont done pas des molecules minerales qui s'orga-
nisent, mnis bien des particules organiques qui sont appelees
a nne nouvelle vie.' He further states that though he believes
that it is the contact of different bodies which gives rise to the
' Heterogenie im Traitr de hi Gl-ncrotwn spontant'c hasr siir des nourcllcs
experiences. Pjiris, 1859.
1.34 SPONTANEOUS GENERATION.
development of proto-organisms, yet he does not think that
their origin is due to affinity alone — vital force must also come
into play. This vital force owes its manifestation to certain
unknown concomitant circumstances ; thus fermentative or
catalytic phenomena precede all spontaneous generation. In
connection with these views he describes the development of
ova in what he terms the proligerous pellicle, or scum on the
surface of fermenting fluids. With regard to this he says : ' La
generation primaire ne produit jamais un animal de toutes
pieces, mais seulement elle engendre des ovules spontanes
dans le milieu proligere absolument sous I'empire des memes
forces qui fa^onnent des ovules dans le tissu de I'ovaire.'
The essentials for the production of new forms are, according
to him, a putrescible body, water, and air, while heat, light, and
electricity considerably favour the result. Having shown that
the first three are essential, though they need not necessarily
be present in large amount, he proceeds to state the problem
in a very fallacious manner : ' Si I'on admet,' says he, ' que dans
nos experiences la generation ne pent s'operer qu'a I'aide de
trois facteurs, et que c'est I'un d'eux seul qui recele les germes
des proto-organismes, il est evident que si Ton prend chacun
de ces trois corps en particulier, sans s'inquieter nuilement
alors des deux autres, et que Ton demontre successivement
que ce n'est aucun d'eux qui contient ces germes, il faudra bien,
en somme, reconnaitre quand le fait aura ete strictement etabli
pour chacun isolement, que ce n'est done aucun de ces trois
coi-ps qui pent servir d'asile aux oeufs ou aux seminales introu-
vables des etres divers qu'on voit s'engendrer sous les yeux.'
He tests the question in the following manner: 1. With
regard to the first point he says that it is evident that the
putrescible material does not contain the germs of the proto-
organisms since, even though it is charred previously to its
employment, the water in which it is placed becomes rapidly
filled with microzoaires and cryptogams.
Experiment. — 10 grammes of any of the following seeds, maize,
peas, beans or lentils, were placed in an iron spoon and completely
charred ; then the pi'oduct was placed in a glass vessel containing 500
grammes of distilled water and covered with a bell jar. In twenty
days the fluids were found to contain micro-organisms and cryptogams.
POUCHET. 155
2. He next points out that it is not the water which con-
tains the germs because, if one places organic substances in an
artificial water, animalculge and cryptogams still develop.
To show this an artificial water was obtained in the following
manner : — ' Into a large flask with two orifices, water and fragments
of zinc are placed : one of the orifices transmits a tube terminating in
a funnel by means of which sulphuric acid may be introduced into
the flask ; the other orifice is attached to a large horizontal tube filled
Avith asbestos, which leads to a small tube drawn out at its extremity,
and terminating close to the outside of a metal vessel filled with cold
water. The sulphuric acid having been introduced, hydrogen gas is
disengaged, and is lit at its exit from the tube. The flame being close
to the metal vessel, moistens its walls with watery vapour, the result
of the combination of the oxygen of the air with the hydrogen from
the apparatus : and this vapour, being condensed, is caught in a
platinum vessel. The apparatus having been maintained in this
state for three days, 200 gi'ammes of water were obtained, and were
employed in the two following comparative experiments.'
Half of this water was boiled for a quarter of an hour, in order to
kill the germs which might have fallen into it, although he does not
consider that to be necessary. This water was then introduced into
a ves.sel with 5 gi^ammes of hay, which had been raised to a tempera-
ture of 200° C. The vessel was placed in a basin containing a little
water, and the whole was covered with a small shade. In four days
there was a granular pellicle and two species of Paramecia.
The other portion of distilled water was not boiled, and to it was
added hay which had not been heated; the result was absolutely
identical.
3. Lastly, Pouchet states that it is evidently not the atmo-
sphere which disseminates the germs, since he has seen organisms
appear in flasks containing only artificial air, or in flasks con-
taining air which had been heated or which had passed through
sulphuric acid.
He next takes up Schulze's experiment, and jiresents the
following as a counter experiment and as a complete disproof
of the former :^
A vessel of the capacity of one litre was half filled with water, to
which 5 grammes of hay were added. The cork of the vessel was
traversed l)y two tubes each bent at right angles, five centimetres above
the place of exit ; one, the afii^rent, did not descend into the interior
156
SrOXTANEO US GENERA TION.
of the vessel lower than its neck, the other, the efferent, reached to
within one centimetre of the liquid, in order the better to remove the
heavy stagnant gases. To each of the tubes was attached Liebig's
bulbs filled with sulphuric acid. To the efferent was further attached
Fig. 5f».— Pouchet's mode op kepeating Schulze"s experiment.
(FROM POUCHET).
a water aspirator, which was kept constantly acting (Fig. 59). The
cork, &c., were all luted with copal. The fluid was then boiled for
an hour. In twenty-six days spirilla, vibriones, and penicillium were
present in the fluid.
In order, as he supposes, to have more rigorous conditions
than those of Schulze, he introduces the following method of
procedure :
Fig. 60. — Another mode adopted by Pouchet for testing
Schulze's views (from Pouchet).
A flask is used having the capacity of one litre, and having three
necks. This is quite filled with concentrated sulphuric acid. The
first neck contains a bent tube, which by one extremity communicates
with an air pump, while the other extremity passes down to the
rOUCHET. 157
bottom of the acid; through the middle neck passes a siphon, which
commences in the flask at the level of union of the uppei' and middle
thirds, while its other end passes into an empty vessel. The third
orifice contains a tube passing down to the bottom of a second vessel,
but only originating in the first vessel at the very top. This second
vessel, of the same capacity as the other, had been filled with boiling
water ; the first neck allowed the passage of the tube from the first
vessel ; through the central one passed a siphon similarly arranged
to that in the first vessel : while from the third opening a tube led
into a third vessel. This third vessel had the same capacity as the
others, but had only two openings, the fii'st receiving the tube from
the second flask, which, however, did not pass down to the bottom of
the third flask as in the other two cases ; and the second giving exit
to a siphon arranged as before (Fig. 60).
A strong decoction of boiling hay having been introduced into the
third vessel so as to fill it exactly, the whole apparatus was luted with
the greatest care, and thus the apparatus contained only this decoc-
tion, the sulphuric acid and the water which had been previously
boiled. Air was then forced slowly into the sulphuric acid, and
traversing the acid, it collected at the toj), forcing the sulphuric
acid through the siphon ; this air then passed on thiough the second
flask, passing through the water and forcing the water through the
siphon ; and from the second into the thiid vessel, forcing some of
the decoction through the siphon ; then the apparatus was abandone J
to itself, and a quantity of the same decoction was placed outside
for compai-ison. In twenty days the hay infusion, both in the appa-
ratus and in the vessel outside, contained * mucor ' and bacteiia.
A second experiment was done by introducing into the thiixl flask
5 grammes of hay, which had been exposed to the action of steam for
five minutes. The vessel was then filled with boiling water. A
similar lesult was obtained.
Again, he introduced into the third flask filtered water, and 10
grammes of hay exposed for thirty minutes to a temperature of 200° C.
Nevertheless, monads and vibriones weie found.
A similar experiment to Schwann's was also perfonned, the
air in the apparatus just described being passed over a heated
tube instead of through sulphuric acid. Nevertheless, organisms
(penicillium and vibriones) developed. Two flasks (instead of
three) were used, the first being filled with boiling water (this
flask having the three necks as usual, one receiving the heated
air, one for the siphon, and the third leading into the second
158 sroyTAXJSOUS GENERATIOX.
flask), and the second containing boiled decoction of hay and
ha\dn2: two necks. He states that he succeeded more often in
obtaining organisms when filtered, unboiled water was sub-
stituted for the boiled water ; and, as he has already proved, as
he thinks, that water does not contain organisms, he considers it
a matter of indifference whether the water has been boiled
or not !
Similar experiments with artificial air yielded the same
results.
A new objection is then brought forward, viz., that if the
atmosphere be the universal disseminator of germs, the greater
the mass of air in contact with a fluid, so much the greater
ought to be the number of organisms which grow in that fluid.
This he has not found to be the case, and he also points out
that in flasks containing the same fluid, placed close to each
other at the same time, different forms of organisms may de-
velop, a fact which he does not consider capable of ex-
planation on the theory of Panspermism.
Pouchet further examined air dust microscopically, and he
admits that he finds spores of fungi and other microscopic
organisms, but he does not think that they are ever present in
sufficient quantities to explain the numbers which are found
in an infusion, for he states that the bacteria themselves do not
increase in number by fission (or but very slowly), but that on
the contrary each is spontaneously generated.
To prove thut organis)iis do not in tlie main come from the air he
took five gi'ammes of dust from the I'oof of the Ruuen Cathedral, and
placed it in 100 gi'ammes of distilled water. Then in another similar
vessel he placed 100 grammes of distilled water, containing tive
grammes of the dry stalks of China aster, previously exposed for two
hours to a temperature of 200° C. These two vessels were placed
under the same glass shade. Eight days later the first contained
vibriones, monads in small numbers, and a few kolpodes. The second
was full of monads and kolpodes.
During a later research Pouchet examined the dust which
collected in the lungs and bones of birds, and he states that
there can always be found evidences of the locality in which
the birds lived. For instance, this dust in the case of forest
CRITICISM OF rOUCIIET'S EXPERIMENTS. 159
birds contains fragments of wood, leaves, starch, &c. He says
that -he never found spores of plants nor ova of microscopic
animals nor encysted animalculge. That he should not have
found spores of fungi, which one would think are more nume-
rous in the forest air than starch granules, is inconceivable,
unless it is supposed that there is a special provision in the
animal economy which prevents their entrance into the lungs,
though permitting the admission of starch granules. The
probability is that he did not recognise them.
Not only does Pouchet sup})ort the doctrine of the spon-
taneous generation of bacteria and the lowest foi^ms of animal
or vegetable life, but he is also prepared to accept the spon-
taneous origin of fleas, acari, and cysticerci !
If, now, we carefully examine these experiments, we shall
see that they are full of the grossest blunders. Take, for in-
stance, his experiments to show that organisms are not present
in putrescible substances, in water or in air. The first experi-
ment is simply absurd. Some seeds are charred and introduced
into a vessel containing distilled water, and covered with a bell
jar ; organisms develop. What does this prove ? Does it
prove that organisms were not present and may not constantly
be present in putrescible substances exposed to the air ? No.
It merely proves that this cannot be their only source ; for here
the water and the air were not heated or otherwise purified, and
therefore the organisms might be easily communicated through
them.
Again, to prove that water does not contain them, an artificial
water is prepared, boiled for a quarter of an hour, placed in an
unpurified vessel containing some hay, which had been pre-
viously heated and exposed to ordinary air. What does this
show ? Certainly not that ordinary water does not contain
organisms. Even admitting that this specimen of water did
not contain them, there was ample explanation of their 2:»resence
from the fact that the fluid was put into an impure vessel,
and that the air had access to it.
Nor is Pouchet more successful in liis attempt to show that
the air is not the vehicle.
In considering the question as to the presence of organisms
or their spores in the air Pouchet puts forward the idea that if
160 SFONTANEOUS GENERATION.
organisms were present in the atmosphere in sufficient numbers
the atmosphere would be totally obscured. But it has been
asserted and shown by Pasteur and others (as we shall see later
on) that organisms are by no means so numerous in the atmo-
sphere as was formerly supposed, but that they are generally
derived from dust which has settled or from water. Further,
Tyndall has shown, by means of the beam of light, what
numbers of minute particles fill the air around us, and up to a
certain point, instead of obscuring it, really render the light
visible.
In his repetition of Schulze's experiment it must be admitted
that Pouchet has a stronger case, but even here the flask and
the tubes were not purified, the quantity of fluid as compared
with the size of the flask was very small, and there is always
the possibility of a flaw in the cork or in the joinings of the
various tubes. And further, this experiment loses its force
when Pouchet admits that he does not always get organisms,
and states, on the contrary, that, when a simple apparatus is
employed, a negative result is obtained. Thus to quote his
own words : ' Dans un appareil a simple rentree d'air ' (this
consists of a flask having only one tube passing through its cork,
to which tube Liebig's bulbs are attached, see Fig. 61 ), ' et dont
les boules de Liebig contenaient de I'eau, on remplit le tiers du
ballon de colle de farinelegere: que I'ony tient quinze minutes
en ebullition a I'aide d'une lampe. Celle-ci eteinte. Pair rentra
dans I'appareil en traversant I'eau peu-a-peu. L'appareil fut
abandonne deux mois a une temperature moyenne de 14
degi-es, et pas la moindre moisissure ne se declara a la surface
de la colle durant tout ce temps.
' Au contraire un criterium, place a cote et en contact avec
I'atmosphere, avait au bout de cinq jours toute sa surface
envahie par des champignons.
' Une experience enterprise le meme jour et dans les memes
conditions, mais dans laquelle Pair est introduit dans l'appareil
en traversant des boules de Liebig remplies d'acide sulfurique,
donna absolument les memes resultats.'
Thus Pouchet showed that not only was Schulze's experi-
ment successful, when performed with a simple apparatus, but
he fiu-ther demonstrated that it was not necessary that the air
CRITICISM OF FOUCHET'S EXFERIMENTS.
161
should pass through sulphuric acid ; if it were merely tuashed
in water it was sufficient.
Again, ' Dans notre appareil a simple rentree d'air, et dont
les boules etaient remplies d'eau, on mit 175 grammes d'urine
humaine et on I'y tint en ebullition pendant un quart d'heure.
Ensuite Fair rentra en traversant I'eau et I'appareil fut
abandonne sous I'influence d'une temperature moyenne de 12
degres. Deux mois apres, I'urine etait encore parfaitement
limpide et pas la moindre moisissm-e ne s'etait declaree a sa
surface. Un criterium place a cote, au
bout de huit jours, etait envahi par
une abondante vegetation crypto-
gamique.
' Une experience est faite le meme
jour et absolument dans les memes
circonstances, seulement Fair ne rentre
dans I'appareil qu'en traversant des
boules remplies d'acide sulfurique. Le
resultat est absolument le meme que
dans I'experience precedente : I'm-ine
est intacte.'
Such are exainples of Pouchet's
general results with this simple ap-
paratus, and, when he states that with
the more complicated arrangement,
even with much more prolonged boil-
ing, he generally obtains cryptogamic
vegetation, I do think that I am only
drawing a fair inference when I sup-
pose that there was something defective about his apj)aratus.
Nor is he more fortunate with Schwann's experiment.
Referring to Pasteur's results — that when he (Pasteur) per-
formed Schwann's experiment of having in contact with fer-
mentescible substances only previously' heated air, he obtained
neither fermentation, nor yeast, nor infusoria — he says : ' L'air
calcine a ici encore arrete la fermentation et les i)roduits
organiques qui en derivent ; cet air est done egalement
iiiipropre au developpement de phenomenes chimiques, comme
il Test a celui des phenomenes vitaux. L'experieuce de
M
M
l( Inaiiiiiiiiiiuiiiiiiniiil \\
Fia. 61. — A PI3IPLE MODE
OF REPEATING SCHULZE'S
EXPERIMENTS (FROM POU-
CHET).
1G2 SPONTANEOUS GENERATION.
Schwann, et celles qui ont ete calquees siir elle, sont done
absolument insignifiantes.' Truly a strange interpretation of
the facts, more especially as he had previously attempted to
demonstrate that calcined air and air which had previously
passed through sulphuric acid were equally incapable of pre-
venting the development of organisms, and as in the ' more
rigorous " conditions under which he performed the experiments
he found that organisms always developed !
Looking more closely at these so-called ' more rigorous '
conditions, we find that they contain a sufficient number of
loopholes to explain the result.
What are we to think of the third experiment to show that
the air is not the vehicle of these organisms ? An impure
vessel is taken, containing dust, and unboiled filtered water is
introduced into it along with some heated hay. Is it any matter
for surprise that organisms are found here, however pure the air ?
The dust in the vessel contained plenty of their spores, the
various tubes passing into it contained dust and impure air,
while the water itself was teeming with organisms or their
spores. And similar objections may be urged against, the first
and most rigorous experiment. Boiling hay infusion is intro-
duced into a vessel containing dust ; no attempt is made to
destroy the septic properties of this dust or to purify the air
and the dust in the tubes leading to and from it. Air is now
forced into the infusion, carrying along with it the organisms
which Pouchet ought to have known were theoretically present
in the air in the last connecting tube, as well as on the walls
of that tube. This is the ' rigorous ' experiment, which is
sufficient ' to overturn the experiments of Schwann and
Schulze.' It is needless to pursue the criticism of such methods.
The following experiment is stronger, and he considers it
sufficient to upset those of Schwann and Schulze. A flask was
introduced to the bottom of a vessel containing a decoction of
barley, which had been kept boiling for six hours. The flask
being completely filled with this fluid, was brought to the sur-
face and corked, and then the circumference of the cork was
surrounded by varnish. On the sixth day a deposit of yeast
was seen, and the flask burst on the seventh.
Here an impmre vessel, cork, &c., were used, and the heat
rOUCHET. 1G3
was not applied to them for a sufficient length of time. Fur-
ther, the fluid cannot have been boiling when the vessel was
introduced and corked, otherwise, if he had done it efficiently,
the operator would have scalded his fingers. It is, moreover,
noteworthy that Pouchet only got organisms in one experiment
of this kind.
In his ' Micrographie Atmospherique,' Pouchet falls into
the great error of assuming that organisms do not subdivide
quickly enough to account for their rapid appearance in infu-
sions. Now it has since been made out by several observers
that organisms do divide with sufficient rapidity, and of this I
may mention two instances from Mr. Lister's work. In the
course of observations on a form of micrococcus, which he terms
' Granuligera,' he found that in little more than an hour and a
half they had trebled their numbers, a fact which he made out
by observing the subdivision of a little group. And with re-
gard to the Bacteriuvi lactis, he found definitely by nume-
ration that it doubled by fission in an hour, so that given one
BacteriuTYi lactis there would be in twenty-four hours no less
than 8,388,608 bacteria ; and other forms of organisms deve-
lop even more quickly.
Then, again, Pouchet objects that with free access of air, a
greater variety of forma ought to be found, but it must be
remembered that what may novu-ish one form may not be good
for another, and that the products of the growth of the form
which in the first instance was most vigorous and most nume-
rous, may interfere seriously with the growth of other varieties ;
and in the experiment which he mentions it is quite evident
that in the vessel to which the dust was added there is little
or no nutriment compared with that contained in the stalks of
the China aster. And lastly, when he 2)laces similar infusions,
similarly treated, in flasks of the same size, under the same
glass shade, and in similar conditions, and finds that the organ-
isms which appear differ in form in the two flasks, he does not
obtain, as he supposes, a proof of spontaneous generation, but
the contrary. For on that theory the same infusion, in the
same conditions, ought to give rise to the same species of
organisms ; and the occurrence of different forms can only be
explained by su})posiiig that different spores gained access to
M 2
164 SPONTANEOUS GENERATION.
the various infusions, a view quite in accordance with the theory
of Panspermism.
Appearing shortly after Pouchet's work, and leading to
diametrically opposite conclusions, were the researches of M.
Pasteur, which have by many been considered as administering
the death-blow to the theory of heterogeny.
Pasteur,^ in his account in the ' Annales des Sciences
naturelles,' begins by attempting to demonstrate the exist-
ence of spores in the atmosphere, a fact which Pouchet had
previously admitted. Such attempts are, however, very un-
satisfactory, partly from the difficulty of recognising what are
and what are not spores, and also from the fact that if spores
do exist they must be so excessively minute as to be in many
cases invisible under the microscope. Professor Tyndall has
shown, by means of the condensed beam of light, the existence
of innumerable solid particles in fluids, in which but few could
be detected by the microscope. Pasteur certainly demonstrated,
and this is generally admitted, that spores of fungi do occur in
the atmosphere. It is not necessary, however, to have this
demonstration of the existence of spores, for the matter can be
set at rest by experiment alone, and it is these experiments,
and not the demonstration of the existence of spores of fungi
in the atmosphere, which give the value to Pasteur's work.
Operating with an albuminous saccharine fluid, in the man-
ner described below, Pasteur always succeeded in preventing
the growth of organisms in that liquid, in presence of heated
air. ' J'ai certainement eu I'occasion de repeter plus de cinquante
fois I'experience, et, dans aucun cas, cette liqueur, si alterable,
n'a donne vestige de productions organisees en presence de I'air
calcine.'
Into a flask with a capacity of 250 to 300 com. were introduced 100
to 150 com. of the saccharine albuminous fluid. The neck of this
flask, which had been drawn out, was then connected with a platinum
tube in which the air could be raised to a very high temperature.
The fluid was boiled for two or three minutes, and then the calcined
air allowed to enter.
Although the experiment succeeded in the case of the
Annales des Sciences naturelles, surie 4, t. xvi. 1861.
PASTEUR. 165
saccharine albuminous material, and some other fluids, it did
not succeed with milk. Leaving milk out of consideration for
a moment, it was shown that other fluids which, although pre-
viously boiled, when exposed to ordinary air, rapidly become
the seat of development of organisms, remain barren when
exposed to heated air. (It has been remarked by several
authors, especially by Pouchet, that Pasteur was unable to
succeed, in many cases, in repeating Schwann's experiment
with calcined air. This is true : but the experiment which
failed was the one where the flask is inverted over mercury,
and the calcined air then introduced, and Pasteur has pointed
out that it is from the mercury that the source of contamina-
tion is derived.) It remained to enquire further what happened
when dust which had not been heated was introduced into the
Fig. 62.— Pasteur's mode of introducing dust into flask con-
taining CALCINED AIR.
h, the fla.sk containing the infusion sealed after being filled witli heated air. a, piece of asbestos
containing dust. When the tube in which this rests lias been purified and filled with heated
air, tiie neck of the flask 6 is broken at c, and the dust slipped in. The neck of the flask is
again sealed. (From Pasteur.)
fluid in presence of heated air. This was done ; the air coming
in contact with the boiled fluid was, as in the former case, pre-
viously heated, and the fluid had remained barren for one or
two months; then precautions being taken that no unheated
air was introduced, unheated dust was put into the flask (Fig.
62), and, as a consequence of this, development of organisms
rapidly occurred, and these organisms were of the same kind
as those which appeared in fluids freely exposed to air. Thus
Pouchet's objection to Schwann's experiment (viz., that heated
air interfered with the growth of organisms) was completely
up.set.
Fresh urine behaves in exactly the same manner when
treated in the two ways described.
In the case of Tnilk Pasteur was, however, unsuccessful
when the boiling temperature was maintained for only two or
16G SPONTANEOUS GENERATION.
three minutes (a length of time quite sufficient in the former
cases) ; and this want of success he believes to be due to the
fact that in this fluid organisms can resist the boiling tempera-
ture for a longer period than in other liquids. Two or three
minutes of a temperature of 110° C, or a prolonged tempera-
ture of 100° C, werej however, sufficient to sterilise milk. This
resisting power he considers to be due to the alkalinity of the
fluid, for he finds the same difficulty if he renders his sugared
yeast water alkaline by the addition of carbonate of lime. In
the case of milk and of the latter fluid, thus purified and pre-
served unchanged for some weeks, the addition of the atmo-
spheric dust, in the way described, produces the same results as
in the fluids previously referred to.
But it is not necessary to use calcined air, ordinary air will
be equally inert, if only it has had opportunity to deposit its
dust before being admitted into i\ie flask. This he showed to
be the case by his well-known experiments with flasks with bent
necks. Into a flask a suitable quantity of the fluid to be ex-
perimented on is introduced, the neck is then drawn out long
and bent in various directions (Pasteur only figures one long
curve) so as to present obstructions to the entrance of solid
particles along with the air (see Fig. 3, p. 16). The fluid is
then boiled for the requisite length of time, and, the lamp
being removed, ordinary air is allowed to enter. Fluids may be
prepared in this way, and preserved for any length of time de-
sired. On the other hand, if the neck be straight, so as to
allow the dust to fall readily into the flask, organisms appear,
however long the neck. In the same way, if the neck be
broken off short, so that there is no obstruction to the entrance
of dust, organisms rapidly develop.
In the case of milk the boiling point must be raised to
about 110'" by heating the fluid under pressure, or the milk
must be boiled for a long time.
That the cause of the growth of these organisms is not
continuous, as would be the case were it some known or un-
known force, but that it is the advent to the fluids of solid
particles floating in the atmosphere, is likewise demonstrated by
the following experiment. Flasks containing the saccharine
yeast solution were j)repared, and sealed during boiling. These
PASTEUR. 1C7
jQasks being opened in different places, with certain precautions
against the admission of dust from its neck, &c., air rushed in,
carrying with it any suspended dust. The neck of the flask
was again sealed, so as to prevent any further entrance of dust.
It was thus found that the air in some places and under some
conditions contained none of the particles which give rise to
organisms, while, on the other hand, when they were present the
organisms might be of very various kinds. One of the situ-
ations in which such flasks could be opened without any de-
velopment of organisms, was in some cellars which had not
been entered for a long time, and in which the dust had there-
fore settled. Precautions were of course taken that the
operator neither introduced the particles himself nor stirred
up the dust of the cellar.
I may quote one experiment : I^e 14 aout 1860 j'ai ouvert et
renferme dans les caves de TObservatoire dix ballons contenaut de
I'eau de levure de biere, et onze autres ballons de la meme preparation
dans la cour de I'etablissement. ;\ 50 centimetres du sol, par un vent
leger. Tous ont ete rapportes le merae jour dans I'etuve de inon
laboratoii-e, dont la temperature est de 25 a 30 degres. J'ai conserve
jusqu'a ce jour tous ces ballons. Un seul de ceux ouverts dans les
caves renferme une production vegetale. Les onze ballons ouverts
dans la cour ont tous fourni des Infusoires ou des vegetaux du genre
de ceux que j'ai deja decrits.'
But the greatest blow was given to the views of the hetero-
genists when Pasteur demonstrated that albuminoid materials
are not necessary for the development of bacteria and fungi,
but that they can be replaced by crystalline salts, such as
phosphates and salts of ammonia. He prepared a fluid
of the following composition, in which these organisms readily
grew : —
Eau pure 100 grammes
Sucre canrli ........ 10 ,,
Tartrate d'ainmoniaque . . . . . 2i\5 „
Cenrlrcs fondues de levure de bii'^re . . . 4 „
' Si Ton seme dans cette liqueur, en presence de I'air cal-
cine, les poussieres qui existent en suspension dans Fair,
1G8 SPONTANEOUS GENERATION.
on y voit naitre les Bacteriums, les Vibrions, les Mucedinees
&c."
Here there is no question of albuminoid particles com-
bining to form an organism. If they develop here sponta-
neously they must be built up from mineral salts.
Such is Pasteur's first work — the work which is considered
by many to have struck the final blow at heterogenesis. Let
us see what it really does prove.
It shows that a certain number of boiled fluids prone to
the development of organisms can be preserved, without any
growth of organisms in them, in the presence of calcined air,
or of ordinary air, the dust of which has been allowed to settle ;
that the introduction of dust into these flasks is the only con-
dition requisite for the development of organisms ; that the
source of organisms is something discontinuous — particulate ;
that organisms are not necessarily the result of changes in
albuminoid materials, for they grow vigorously in an artificial
mineral fluid. Further, Pasteur has shown that among the
particles present in the dust of the atmosphere there are
spores of fungi and bodies which may be bacteria or their spores.
This is all that is proved by these experiments ; and how
does Pouchet answer them ? By asserting that these solid par-
ticles are not bacteria or their spores, but lifeless particles,
which under certain conditions become vivified, and appear as
various forms of organisms ? The only possible theory, one
would think ! No. Pouchet disputes the facts. He does not,
it is true, take the trouble to repeat Pasteur's striking experi-
ment of the flask with bent neck. He simply says : ' C'etait
une erreur.' Further, ' Nous avons refuse de repeter les ex-
periences de M. Pasteur parce que, logiquement, rationnelle-
ment, pour des physiologistes, du moment oii il est reconnu
' It may be mentioned here that, since Pasteur published, other simihir
fluids in which organisms can grow have been cmploj'ed. Tlius Cohn uses
the following: —
Distilled water
Tartrate of ammonia
Pliosphate of potash
Crystallised sulphate of magnesia
Tribasic phosphate of lime
20 c.cm.
•2 grammes
•1 „
•1
•01
POUCHET'S REPLY.
]69
que celles de Schwann * sont absolument erronees, et je pense
que pas un seul de ceux-ci ne voudrait aujoiurd'hui le contester,
les experiences du chimiste de Paris sont consequemment frap-
pees de la meme nullite.'^
Pouchet again retiu'ns to the simple experiment in repeti-
tion of Schulze's, which we have previously quoted, but now
his statement is directly opposed to that formerly made. He
now says, ' En employant dans cet appareil ' (a simple rentree
d'air) ' de la colle de farine extremement legere, de I'albumine, de
I'urine, de la biere, du foin, ou de la noix de galle, constam-
TYient on voit apparaitre des microphytes ou des microzoaires
apres un temps fort court.' How is this contradiction to be
reconciled ? Is not the former experiment most likely to be
correct ?
Fig. 63.
-Another mode op repeating Schulze's experiment.
(FROM Pouchet.)
He then goes on to describe an experiment ' much more
' rigorous ' than that of M. Schulze.
'Dans un ballon dont le col place horizontalement siipporte un
robinet, je mets une certaine quantite d'eau ordinaire. Un corps
fermentescible renferme dans un gvos tube de veri-e, et qui a ete prea-
' I previously pointed out that Scliwann's experiment, whicii was occasion-
ally unsuccessful in Pasteur's hands, was not that to which M. Pouchet alludes,
but that performed over mercury ; and Pasteur has abundantly demonstrated
the fallacy here and liow it can be overcome.
^ ijee Nouvelles Ej.-pcHenccs sur la (reiteration spontanee.
170 SPONTANEOUS GENERATION
lablemeut cliauffe k 150° C. pendant cinq beures, est plac6 a I'interieur
du col de ce ballon : ce tube est ferme par un opercule rode a I'emeri
et scelle hermetiquementavec lui par line substance facilement soluble
dans I'eau. Le ballon communique avec irois tubes en U et des
boules de liiebig. L'un de ces tubes contient de la ponce sulfurique,
tin autre de la pota,sse causti(|ue, et le troisieme du coton carde.
' Les boules de Liebig sont remplies d'acide sulfurique concentr6.
' A I'aide d'une lampe on met I'eaiT du ballon en Ebullition pendant
dix minutes, et ce n'est qu'ensuite qu'on articule les tubes en U
a I'extremite du tube de Liebig. Enfin on eteint la lampe, et, tandis
que I'appareil se refroidit, I'air extei-ieur y rentre en traversant I'acide
sulfurique, le coton, la ponce sulfurique et la potasse. Quand
I'appareil est parvenu a la temperature ambiante, on fait tomber le
tube dans le liquide, et loi-sque celui-ci a dissous la substance soluble
qvii lute I'opercule, ce dernier s'ouvre et I'eau envabit I'interieur
de ce tube.
* Peu de temps apres, constamment on voit la liqueur du ballon se
peupler de v6getaux et d'animaux microscopiques, selon les substances
que Ton a confinees dans le tube. Jamais en suivant ce proced6
I'experience ne manque.'
Such is the experiment which is more rigorous, certainly
much more complicated than Schulze's. Nevertheless there
are numerous loopholes in it.
Thus this little tube containing the fermentescible material
is cold, and may be covered with dust when introduced into the
neck of the flask. It is certainly strange that, in order to be
certain that organisms should develop, it is necessary to heat
the great bulk of the water used, and the putrescible material
in a small quantity of water separately, and then to unite them
in the manner described. For Pouchet himself admits that he
does not always get organisms with Schwann's simpler method.
Then, again, it is no easy task to cork thoroughly a vessel
heated to the boiling point of water ; and the cork used was in
no way purified. It is true that steam passed over it for a short
time, but then steam is dry heat, and it is generally admitted
that dry heat at the temperature of boiling water is not sufficient
to destroy all organisms. This argument also applies to the dust
on the wall of the vessels. And then in tilting the vessel to
introduce the tube into the water, the joints, unless very
securely fixed, may oj^en, or living dust may be shaken into the
POUCHETS REPLY. 171
fluid from the neck or cork, leaving out of consideration the
fact that it is in all probability carried in with the small tube.
Pouchet looks on this experiment as completely disproving
those of Schulze, Schroeder and Dusch, and Pasteur, and why ?
Because with this apparatushe constantly obtains organisms. How
then does he explain Pastem-'s results ? Pasteur boils his fluids
for two or three minutes, and finds that they remain barren.
This experiment can only be answered by Pouchet (so long as
he adheres to this line of argument) by supposing that Pasteur
is making a false statement, or that by boiling his fluid he has
destroyed its power of producing organisms spontaneously. As
regards the first, a committee composed of the first scientific
men in France confirm the truth of what Pasteur asserts ; while
the second can have no force when looked at in the light of
Pouchet's own experiments ; for we find that the latter obtains
organisms after keeping his fermentescible material at a tempe-
rature of 110° C. for several hours, and boiling the water for from
30 to 60 minutes.
Such a method of reasoning and of experimentation would
not have deserved so much notice were it not for the great in-
fluence which Pouchet's work has exercised and does still exer-
cise on those who have not read or studied it. And I have felt
it the more necessary to consider his work in detail as he is one
of the last observers who has maintained a more or less complete
heterogenesis, and also as I am not aware of any work in which
his experiments have been subjected to a searching criticism.'
' Pouchet's experiments and conclusions were objected to by Mihie-
Edwards, Payen, Quatrefages, Claude Bernard and Dumas, who examined
them, and also those of Pasteur.
172 SPONTANEOUS GENERATION.
CHAPTEE IX.
SPONTANEOUS GENERATION {continited).
The experiments of Jeffries Wyman : exi^lanation of the results : Wj'inan's
views on the subject. Dr. Bastian's views: Cases in which it is still pos-
sible that abiogenesis may occur : Growth in vacuo — Bastian's experiments
— my own results — Cohn's facts — Dr. Roberts's objections, the walls of the
vessels remain impure — Bastian's reply — Objections to the latter — Gruit-
huisen's experiments — Paul Bert's results with compressed air — Pouchet
looks on a vacuum as preventing spontaneous generation — Paul Bert'sresults
with rarefied air — Dr. Bastian does not always get positive results : Ex-
periments in airless and hermetically sealed flasks raised to a high tem-
perature— Objections — Prof. Huxley's and Dr. Sanderson's statements — Ray
Lankester's results — Hartley: experiments with alkaline fluids— Roberts's
counter-experiment. Mr. Lister's experiments. Experiments by Roberts
and Tjmdall.
Other writers, chiefly French and Italian, among whom may be
mentioned Joly, Musset, and Mantegazza, have sn])ported
Pouchet, but as their experiments furnish little or no additional
evidence nor new argument I think it unnecessary to discuss
them. Those of Joly and Musset will be found in the ' Comptes
Kendus de I'Academie des Sciences,' about the same period as
the papers of Pasteur and Pouchet.
I must, however, refer at length to the experiments of
Professor Jeffries Wyman, of Cambridge, U.S. These have been
largely quoted by the supporters of heterogenesis, as proving
their view, though it ought to be borne in mind that Wyman
himself expressed no such opinion. It must be confessed that
at first sight the experiments seem difficult of explanation on
the Panspermic theory, and it is the more necessary to scrutinise
them carefully, as he has evidently approached the subject with
a perfectly unbiassed mind, and has therefore simply recorded
his facts without attempting to force any definite conclusion on
this question from them.
JEFFRIES WYMAN. 173
The following are the facts which have been adduced by
supporters of spontaneous generation as favouring their views.
Flasks were prepared in three ways :
1. 'The materials of the infusion were put into a flask'
(the general relation between the quantity of fluid and the
capacity of the flask was, that about 20 c.cm of fluid were
introduced into flasks of about 500 c.cm. of capacity) ' and
a cork through which passed a glass tube drawn out to a
neck was pushed deeply into the mouth of it. The space above
the cork was filled with an adhesive cement composed of resin,
wax, and varnish. The glass tube was bent at a right angle
and inserted into an iron tube and cemented there with plaster
of Paris. The iron tube was filled with wires, leaving only very
naiTow passage ways between them.'
Into these flasks such fluids as sugar, gelatine, and hay
infusion — cheese, sugar, and gelatine — flesh, sugar, and gelatine,
&c., were introduced, and boiled for periods varying from fifteen
minutes to two hours, while at the same time the ii'on tube,
filled with wires, was heated to redness. On withdrawing the
lamp from the flask, the air which entered passed over these
heated iron wires. When cold the flasks were sealed with the
blow-pipe. Fourteen vessels were prepared in this way. and in
ten of these, when opened after the lapse of various periods of
time, organisms were found, generally vibriones and bacteria.
The other four remained barren.
2. In a second set of experiments the cork in the neck of
the flask was avoided, the neck itself being drawn out and bent
at right angles, and into the orifice of this tube the iron tube
was cemented. The other conditions were the same as in No. 1.
Similar fluids were used here as in the former case, such as
gelatine and sugiir with a few drops of urine and milk, beef
infusion, &c. Thirteen flasks were treated in this way, and in
all organisms appeared.
3. In others the flask was sealed at the ordinary temperature
of the room, after the fluid to be tested had been introduced,
and then it was submerged for a variable period in boiling
water. This was a repetition of the experiments of Needham
and Spallanzani. In :ill llic flasks so treated organisms de-
velo])ed.
174 SPONTANEOUS GENERATION.
Four experiments were made under pressure, and of these
two gave evidence of life (' monads and vibrios '), the other two
remaining barren.
Such facts coming from an accurate and totally imjirejudiced
observer cannot be dismissed lightly. It is quite evident, on
reading Wy man's paper, that the facts are accurately narrated,
and we must therefore see whether any flaw can be detected in
the method of experimentation, and we must attempt to find
some explanation of results so diametrically opposed to those
obtained by Pasteur which are, it must be remembered, equally
indisputable.
Now, if we compare this method with that adopted by
Pasteur, we shall see that with one exception the essential
details are the same. This exception is, however, an extremely
important one, and is probably the explanation of the diverse
results obtained by several honest workers, and even by the
same worker at different times. Pasteur takes a flask having a
capacity of 250 to 300 c.cm., and into this 100 to 150 c.cm.
of the liquid are introduced. Wyman uses flasks varying from
500 to 800 c.cm. in capacity, and into these he puts 12 to 40
c.cm. of the liquid. (In neither case was there any attempt
at preliminary purification of the walls of the flask or of the air
in the interior.) In Pasteur's experiments the fluid occupies
^ or more of the capacity of the vessel ; in Wyman's only -J^
to -3^ part.
Such is the only important difference between their methods ;
and this affords, I believe, sufiicitsnt explanation of the opposite
results. For in Pasteur's flask only a proportionally small
part of the wall of the flask has to be purified by the steam,
and the extent of this part is of course much diminished, by
the ebullition of the fluid during boiling. There is also in
Pasteur's flask only a very small quantity of air, Avith its dust,
to be acted on. It is thus not to be wondered at that a
barren result was obtained. But in Wyman's experiments
by far the greater part of the flask and of its contents is
impure, and can only be purified by the steam. Now steam, as
heat, must be looked on as dry heat, and it is stated by Wyman,
in a later publication,' that certain forms of organisms may
' American Journal of Science, vol. xliv. 18C7.
JEFFRIES WYMAN. 175
resist the prolonged application of even a higher dry tempera-
ture than 212° F. Wyman also points out that the tempera-
ture of the air even half an inch above the surface of boiling
water is many degrees below the boiling point. How much lower
then will this temperature be at the orifice of this large flask
during the greater part of the time in which the fluid is
boiled ? But even admitting that steam is moist heat (what I
am by no means disposed to allow) several remarkable instances
of vegetable growth at high temperatm'es are produced by
Wyman, in one case even at a temperature of 208° F.
Such is the explanation I would give of Wyman's results,
and that this is a true explanation will be very evident when I
come to the consideration of the method of experimentation
adopted by ]\Ir. Lister. This explanation accords in every way
with my own experience, in which I could point to several
similar instances.
As I ?iave said, Wyman is generally quoted in support of
the theory of spontaneous generation, and at one time I thought
that he had entertained that view, but the following facts
brought to my notice by his brother. Dr. JMorrill Wyman, show
that he never gave any expression of opinion on this point, and
that he appreciated the possibility of such an explanation of his
results as I have given.
His first article is entitled ' Experiments on the formation
of infusoria in boiled solutions of organic matter enclosed in
hermetically sealed vessels and supplied with pure air,' ' and his
second, ' Observations and experiments on living organisms in
heated water.' ^ With regard to the object of his research he
says, ' The observations and experiments contained in this com-
munication have not been brought together either for sustain-
ing or refuting the doctrine (spontaneous generation) just
referred to, but partly with the view of testing the accuracy of
the experiments formerly made, and chiefly for the puri)Ose of
determining how far the life of certain kinds of low organisms
is either sustained or destroyed in water which has been raised
to a high temperature, a result which must be readied before
spontaneous generation can be either asserted or denied.'
' >Sillimft/i'.i Jiiin-nal, vol. xxxiv. 1SG2.
- Ihid, vol. xliv. 1S(;7.
176 SPONTANEOUS GENERATION.
With regard to his experiments he says, ' In the first
experiments the red hot tube, beyond a question, destroys all
organisms contained in the air which enters the flask through
it, but is without effect on such as may be contained in the
solution, or adhere to the inner surface of the glass. These
come in contact only with boiling water or steam, and unless
destroyed by one or the other of these would be sufficient to
vitiate any experiment, however careful the adjustment and
heating of the tube may have been. We therefore believe that
the tube is an unnecessary and useless complication of the
apparatus.'
In another set of experiments it was shown ' That if the
boiling of the flasks was continued for four hours, the infusoria
may appear nevertheless — though in other cases it has happened
that life ceased to be manifested if it was continued only for
two hours.' ' In pushing the experiment still further, we have
not found that infusoria appeared in any instance if the boiling
was prolonged to five or six hours.' Several experiments, in
which many flasks were used, were tried, but ' the result was
uniformly the same. Thus a limit to the development of
infusoria in boiling water was reached.' Dr. Wyman tells me
that in the summer of 1880 he examined one of these flasks,
which is marked as having been prepared in June, 1867, and
which has remained unopened ever since. ' Judging by the
signs above given ' (absence of scum, of muddiness, or of fer-
mentation) 'there is no evidence of infusorial life.'
The last defence of heterogenesis which it is necessary to
consider is that by Dr. Bastian.' He gives up the theory of
organic molecules derived from previously living molecules,
and attempts to demonstrate that vital force and living matter
may arise de novo under the action of the ordinary physical
forces — heat, light, electricity, &c. This change of front on the
part of the heterogenists is clearly brought about by the over-
whelming evidence produced against Pouchet's views, and more
especially by Pasteur's success in cultivating organisms from
dust in fluids containing no organic matter. A further admis-
sion is made which somewhat simplifies the question, viz., that
organisms have the power of self-multiplication.
' The BcfjinniiKjs of Life, 1872, &c.
BASTIAN. 177
The limitation of cases of spontaneous generation, which
has been gradually taking place, is exceedingly instructive.
Beginning with the higher animals, it became gradually more
limited, frogs, flies, &c., being by degrees excluded, till now it
is only in the case of the lowest forms of life that the doctrine
is asserted, and even there only in certain instances. The cases
which are yet doubtful are given by Eastian in the work
quoted, and may be grouped into three divisions.
I. The first division relates to the development of organisms
in various fluids, more especially m vacuo — a condition which
Pouchet looked on as inimical to life !
Into flasks portions of various infusions were introduced. The
latter were then boiled for from ten to twenty minutes, and hermeti-
cally sealed while still boiling. The fluids used were turnip and hay-
infusions, o.nd also solutions of certain salts, chiefly citrate of iron
and ammonia coutainiug portions of wood, cheese, &c.
The conditions of the first experiment mentioned are very
striking and unusual.
' A closed flask containing a very strong infusion of hay
(boiled for five minutes), to ivhich had been added 7,\th part of
carbolic acid, was opened twelve days after it had been hermeti-
cally sealed.' Bastian states that this flask contained organisms
of a peculiar form.
Such a statement as this, that a saturated solution of carbolic
acid (for a watery fluid at the ordinary temperature containing
-Jjjth part of carbolic acid is saturated) can jjerinit the growth
of organisms, is absolutely opposed to all experience and ex-
periment. In experimenting with turnip infusion, cucumber
infusion, &c., I have never been able to grow any sort of organ-
ism in these fluids, when they contained a larger proportion of
carbolic acid than 7, y- th part, even though several drops of fluids
swarming with bactt'ria were introduced. Further, I liave lately
jicrformed the following experiment : — In January 1880 I intro-
duced carbolic acid into flasks containing strong unboiled hay
infusion so as to have a strength of the acid present, varying from
1 in 20 to 1 in 200 [)arts. Tlu'se flasks were then covered with
cotton-wool caps, and placed in an incubator. When examined
six weeks later, there had not yet appeared in any one of them
N
178 SFONTANEOUS GENERAriON.
any sort of organism. And lastly, tliis statement, that organ-
isms can develop in acid fluids after boiling, is contrary to the
whole tenor of Dr. Bastian's later remarks, for his strong point
is the develo})ment of organisms in alkaline — not in acid — fluids
after })ro]onged boiling.
Bastian also employs turnip and hay infusions (without
carbolic acid) and solutions of such salts as citrate of iron and
annnonia, and he finds that a slight sediment occurs which
contains organisms. He generally has to introduce such
things as deal wood, cheese, &c., in order to get this result.
With regard to experiments on such fluids as hay infusion
and turnip infusion without cheese, I may state that I have
quite lately repeated them with exactly op})osite results. At
first I proceeded to repeat them, following closely Dr. Bastian's
directions, in the expectation of getting organisms, and looking
out for some explanation of their occurrence. The physical
forces, or whatever else it may be, were, however, not favourably
disposed for spontaneous generation at the time and place
where I performed those experiments, for to my surprise I
was unable to obtain any development of organisms. I tried
several modifications, in the hope of finding the cause of their
absence, but whichever of these vegetable fluids I used I was
able, with proper precautions, to preserve them with the
greatest ease. Some specimens were very difficult to filter,
and in some a slight muddiness occurred on boiling, and the
granular de])Osit might very readily be mistaken at first sight
for organisms, though some care and experience would easily
prevent such an error. But I have boiled the fluids for
a few minutes and then filtered them under pressure (I could
not in this way remove any of Dr. Bastian's supposed physical
forces) , and having thus obtained a perfectly clear liquid, 1
treated it like the others. There was now no deposit, and
nothing which could be mistaken for organisms.
No doubt other observers have produced evidence which
apparently at first sight supported Dr. Bastian's views. I
refer to the class of experiments in which prolonged boiling
was required for sterilisation, but many of these results depend,
I believe, on the same causes as Wyman's, viz., imperfect puri-
fication of the walls of the flasks and of the air in their interior,
COHN'S REPLY TO BASTIAN. 179
while the fact, that in some instances such resistance was met
with, surely implies the presence of some form of encysted
organism or resisting spore, or of an organism placed under
conditions in which it is not perfectly heated, rather than
some rare form of organic molecule or physical force.
The former view — that there is present in the infusions
some form of resisting spore which can withstand the high
temperature — was shown by Cohn to be correct in the case of
the experiments where portions of cheese were introduced.^
He repeated Bastian's cheese experiments with great care, and
found that after exposure to a temperature of 100° C. for ten
minutes, organisms still developed in the mixtm-e of cheese
and tm'nip. He, however, observed that these organisms were
always of one form {Bacillus subtilis), and that Bacterium tenno
and other forms were absent. On investigating this subject
further he found that these bacilli did not merely grow in the
form of long rods, but that they produced spores, and he had
previously ascertained ^ that the spores of these organisms were
possessed of peculiar resisting powers. Indeed, such was their
power of endurance under high temperatures, that if some
satisfactory explanation could be given why they should
always occur in these experiments, the whole mystery would
be solved, and the theory of spontaneous generation would no
longer be supported by these facts.
Cohn therefore turned his attention to the manufacture of
cheese. The Swiss cheese is made in the following manner :
milk is placed in large copper vats, and is coagulated by the
addition of rennet. This is allowed to stand for a quarter of
an hour, and then, after having been kept at a temperature of
from 55° to G0° C. for an hour, it is broken up into small
masses. These are now taken up in a cloth, placed in a
mould, and pressed for twenty-four hours. The cheese is then
taken out of the mould, transferred to a cellar, and kept at a
temperature of 10° to 12° C. for several months, salt being
daily rubbed over its surface. Lastly, it is stored till it
attains its full ripeness.
' See UnterxuckuiKjcn iibcr Bactmcn, Cnhti'x Jieitriii/e zuv Biulwjic der
I'Jtanzcii, Erster Band, Urittes Heft, p. 188.
« Colin, ibid., lleft 2, p. 17G.
N 2
180
SPOXTANEO US GENERATION.
The only stage in the process which it is necessary to con-
sider is the ripening of the cheese. Cohn points out that this
is a true fermentation clue to the growth of organisms ; this
YiG. 6-t. — Bacillus subtilis ; without spores ; with spores in the
RODS ; FREE SPOKES ; X GOO (AFTER COHN).
fermentation begins during the first twenty-four hours, while the
curd is still under the press, and is accompanied by the develop-
ment of large quantities of gas. The slower development of
this gas, which occm'S later, explains the
formation of cavities in the cheese. The
chemical change consists in the partial
transformation of the milk sugar into
butyric acid. The preliminary heating
to 55° or 60° C. kills all the organisms
except the bacilli which give rise to this
butyric fermentation. On examining
the rennet Cohn found that it was full of
bacilli, many of which contained spores,
and of free spores. By the addition of
the rennet to the milk enormous num-
bers of these spores are sown in it, and
the subsequent stirring mixes them
thoroughly with it. These spores escape death at the tem-
perature of 55° — 60° C, and develop in the cheese, thus
causing its ripening. They have been shown to resist high
Fig. 65. — Deposit in
rennet, consisting
of a mass of micro-
cocci and spores of
bacilli, x goo (af-
ter c'oiin).
ROBERTS'S OBJECTIONS. 181
temperatures, and, when used in Bastian's infusions, they are
not destroyed, and thus we have a satisfactory explanation of
the frequent development of bacilli in these experiments.'
The other view — that the organisms were imperfectly
heated — was urged against Dr. Bastian's experiments by Dr.
Roberts as long ago as 1873. After pointing out that atmo-
spheric germs may get into the flasks at the time of sealing, he
goes on to a second source of error, which he considers much
more important. ' It is this : Dr. Bastian's process does not
insure that the entire contents of the flask are effectively
exposed to the boiling heat.' He refers to the difficulty in
boiling milk and other substances, owing to the spurting and
frothing of the fluid ; but he shows that if this is avoided by
simply immersing the flasks in boiling water, the difficulty in
rendering them ban-en is overcome. He says : ' The essential
conditions of the experiment are first the effective exposure of
the whole contents of the flask to a boiling heat ; secondly,
the absolute prevention of any fresh entrance of extraneous
solid or liquid particles ; and the conclusion I have come to is
that if these conditions are rigidly observed, the flasks remain
barren. If they do not remain barren it is simply because one
or other of these conditions has not been observed.'
In answer to this Dr. Bastian ^ replies : ' I feel quite sure
that in my experiments no portion of the inner surface of the
glass has escaped the scathing action of the boiling fluid. The
vessel has generally been more than three-fourths full before
the ])rocess of heating has been commenced, so that where
ebullition occurs the fluid has always swept over the previously
uncovered inner surface and, as Dr. Sanderson testifies, " dur-
ing th(! boiling some of the liquid was frequently ejected from
the almost cajjillary orifice of the retort." The inner surface of
the vessel was, in fact, always thoroughly and re[)eatedly
washed with the boiling fiuid, nearly half of which has been
spurted away in order that I might effect this object.'
Now it is just tlie spurting of the liquid which is so danger-
' Tlie experiments of Huizinfja, on whicli P.astian lays ^eat stress, have
been refuted b}' Samuelson {P/fiitjcr's Arc/tir, viii. p. 277) and }>>■ Gscbeidlen
(Ifnd. ix. p. 163).
* Nature, Februarj- 27, 1873.
182 SPOXTANJEOUS GENERATION.
ous, for, with the bubbles, solid particles are carried up and
deposited on the neck or sides of the flask, out of reach of the
boiling liquid, and they may not be acted on by the frothing
fluid. I also very much doubt if a bubble of steam sweeping
over the wall is to be regarded as a very efficient way of
applying moist heat ; certainly it is not so efficient as boiling
in a fluid. That greater success is obtained when this spurt-
ing and frothing do not take place has been stated by Dr.
Roberts, and this statement is quite confirmed by Mr. Lister's
experience with milk, where he uses the method of immersion
with perfect success, and for the same reasons.
But surely this view, that the walls of the vessels remain
impure, is the only way in which Bastian's facts can be recon-
ciled with Gruithuisen's experiments mentioned by Bastian
himself in a paper read before the Eoyal Society on March
20th, 1873. I will just quote Dr. Bastian's remarks and
experiments in connection with this paper. It is to be observed
that Bastian used this method for ascertaining the death-point
of bacteria, and the title of the paper in which these state-
ments occur is, ' On the temperature at which bacteria,
vibriones, and their supposed germs are killed when immersed
in fluids or exposed to heat in a moist state.'
He says : ' It was pointed out by Gruithuisen early in the
present century, that many infusions, otherwise very productive,
ceased to be so when they were poured into a glass vessel whilst
boiling, and when this was filled, so that the tightly fitting
stopper touched the fluid. Having myself proved the truth of
this assertion for hay infusion, it seemed likely that, by having
recourse to a method of this kind I should be able to lower
the virtues of boiled hay and turnip infusions to the level of
those possessed by the boiled saline solution with which I had
previously experimented, that is, to reduce them to a state in
which, whilst they appear quite unable of themselves to en-
gender bacteria or vibriones, they continue well capable of
favouring the rapid multiplication of such organisms.
' This was found to be the case, and I have accordingly per-
formed upwards of 100 experiments with inoculated portions of
these two infusions raised to different temperatures. The mode
in which the exjieriments were conducted was as follows :
GRUITHUISEN'S EXrERIMENTS. 183
' Infusions of hay and turnip of slightly different strengths were
employed. These infusions having been first loosely strained through
muslin, were boiled for about ten or fifteen minutes, and then whilst
boiling strained through ordinaiy Swedish filtering paper into a glass
beaker, which had previously been well rinsed with boiling water, A
number of glass bottles or tubes were also prepared, which, together
with their stoppers or corks, had been boiled in ordinary tap water
for a few minutes. They were taken out full of the boiling fluid, and
the stoppers or corks being at once inserted, the vessels and their
contents were set aside to cool. When the filtei'ed infusion of hav or
turnip had been rapidly cooled down to about 110° F. (by letting the
Ijeaker containing it stand in a large basin of cold water), it was
inocxalated with some of a turbid infusion of hay swarming with
active bacteria and vibriones, in the pi'oportion of one drop of the
turbid fluid to each fluid ounce of the now clear filtered infusion.
The beaker was then placed upon a sand bath, and its contained fluid
(in which a thermometer was immersed) gradually raised to the
required temperature. The fluid was maintained at the same
temperature for five minutes by alternately raising the beaker from
and replacing it upon the sand bath. The bottles to be iised were
then one by one uncorked, emptied, and refilled to the brim with the
heated inoculated fluid. The corks or stoppers were at once very
tightly pressed down, so as to leave no air between them and the
sux-face of the fluids. The beaker was then replaced upon the sand
bath and the gas turned on more fully, in order that the experimental
fluid might be rapidly raised to a temperature 9° F. (5° C.) higher
than it had been before. After five minutes' exposure to this tempera-
ture, other bottles were filled in the same manner, and so on for the
various tem^ieratures, the influence of which it was desired to test.'
These bottles were kept at a temperature of from 0)5° to 75°
F. The results were as follows :—
'The experimental results here tabulated seem naturally
divisible into three groups. Thus, when heated only to 131° F.
all the infusions became turbid within two days, just as the
inoculated saline solutions had done. Heated to 158° F. all
the inoculated organic infusions remained clear, as had been
the case with the saline solutions in my previous experiments,
when heated to 140° F. There remains therefore an inter-
mediate heat zone (ranging from a little below 140° F. to a
little below 158° F.), after an exposure to which the inoculated
organic infusions are apt to become more slowly turbid, although
184 SPONTANEOUS GENERATION.
inoculated saline solutions raised to the same temperature in-
variably remain unaltered. ... we may quite safely conclude
that bacteria, vibriones, and their supposed germs are either
actually killed or else completely deprived of their powers of
multiplication after a brief exposure to the temperatm^e of 158°
F. (70° C).'
With the conclusions drawn from these experiments as to
the death point of bacteria, I, for the most part, agree, but I
shall have to refer to them again presently. I have introduced
the facts here, because I believe that they add strong confirma-
tory evidence of one of the explanations of Bastian's results
which I have been trying to establish, viz., that in many cases
the organisms which appeared in his fluids after boiling did
not arise de novo, but were derived from particles on the walls
and in the air of the vessel, which had not been deprived of life.
For in Cxruithuisen's experiments and in Bastian's repetition
of them, there was no part of the wall of the vessel nor any air
in the interior left to be acted on by more or less dry heat.
The vessel was filled with fluid, and all the particles in it were
subjected to moist heat. And here the high temperatures
required in the other cases were not necessary. A temperature
of 158° F. continued for a very short time was sufficient to
render the liquid permanently barren.'
' It is of great interest to mention here tlie difficulties experienced by Dr.
Paul Bert in attempting to preserve meat after subjecting it to high pressure
(' La pression barometrique,' p. 880).
' Ainsi, dans mes premieres experiences, lorsque je voulais conserver une sub-
stance, apr^s I'avoir soumise A, la compression, je fermais d'un bon bouchon de
liege le flacon oi\ elle etait placee : ce bouchon etait perce d'un trou, et lorsque
j'avais retire le flacon de I'appareil, j'appliquais sur cet orifice fin une goutte
de cire fondue, avec laquelle, du reste, je cachetais tout le bouchon.
' Je ne tardai pas tl apprcndre que cette precaution etait insufiisante. Les
bouchons, meme neufs, mcme laves, meme chauft'es rec^lent trop souvent des
germes encore en activite. J'cus alors recours aux matras, ballons, tubes, que
j'etirais 4 1a lanipe, apres y avoir introduit la substance en experience; le
trou presque capillaire de la partic etiree permetlait a I'equilibre de pression
de s'ctablir.
' Je m'aper^us encore, a mes depcns, que les germes restes ill'etat sec sur les
parois du petit recipient suffisaient, surtout quand il s'agissait de la putrefac-
tion, mon laboratoire de dissection en etant bourre, pour t roubler les plienomi^nes.
Je ne pouvais me mettre sCirement a Tabri qu'en ajoutant un peu deau et en
renuiant avec soin le recipient, avant de la soumettrc a la compression, afin
de tuer en meme temps et les germes contenus dans la substance, et ceux des
parois qui se trouvaient mouilles.'
PA UL BERT OX LIFE IX VACUO. 185
But was the fluid in these vessels in any special condition
which prevented the origin of organisms ? It is to be observed
that when the heat was not high enough to kill organisms, they
developed readily, there was then nothing in the conditions
which prevented the development of organisms. The only
difference in the two sets of experiments, and it seems to be
indicated by Bastian, appears to be that in Bastian's former ex-
periments the fluids were under diminished atmospheric pres-
sure, while here they were not. The conclusion then ajjparently
is that a vacuum is better suited for the spontaneous origin of
organisms than the normal pressure ; and that such is Bastian's
view is openly stated by him, and among facts in support of it
we find the admission that turnip infusion, urine, and some-
times hay infusion, may remain for an indefinite time in Pas-
teur's flasks with open bent necks without any development of
organisms in them, while in a vacuum organisms arise in
similar fluids, especially if a piece of cheese has been added to
them.
We must therefore see if any other facts favour this in vacuo
idea. As I have already stated, Pouchet, who is largely quoted
by Bastian, states distinctly that a vacuum is most unfavourable
for the occun-ence of spontaneous generation, and he employs a
vacuum for repeating some of Pasteur's experiments, in order to
showthatas soon as air is admitted, spontaneous generation occurs.
And in regarding a vacuum as inimical to life when com-
pared with the ordinary atmospheric pressure, Pouchet was
con-cct, as will be evident from the following quotations from
Paul Bert's recent remarkable work, entitled 'La Pression baro-
metrique.'
On submitting seeds to low pressures he found that germi-
nation was nmch delayed.
Tims in his 350th experiment ho sowed barley in eartli in tlu^ec
pots, and placed them :
A undei- a glass at the normal pressure.
B „ „ at .50<=' of pressure.
Five day.s later in A the slioots were numerous, very green and
very Gvvn, measuring about 10^-
B less numerous, less green, measuring about 8"^'
C still less, measure about G*^-
186 SrONTANEOUS GENEliATION.
Next day these shoots were cut off at the level of the grain, dried
and weighed :
End shoots of A weighed S'^s-S.
!> )j ;; -" )> ' ■'•
A low pressure was also found tb be inimical to vegetation.
Thus to take his 359tli experiment :
A number of sensitive plants abovit lO'^" in height wei'e each
placed under a bell jar on August 1.
August 1. A at 60<=' of pressure.
B „ 50- „
C „ 25- „
August 3. Some leaves have fallen from C.
August 6. A leaflets sensitive and open.
B „ half open and little sensitive.
C „ completely closed.
August 7. All restored to normal pressure.
They are all sensitive, but C much less so than the others. C
does not close well this evening.
August 9. A is all right, very sensitive.
B. Little sensitive — sickly, yellowish.
C. Leaves falling off — dying.
A similar result, was obtained when putrescible substances
were submitted to varying degrees of low pressure.
Thus in experiment 38G the muscles of a dog were placed :
A at the normal pi'essure.
B at SS"^" of pressure.
Four days later A was horribly putrid.
B is a little less putrid.
Experiment 392. — On January 17, equal sized morsels of meat
were placed :
A in a pressure of half an atmosphere.
B at the ordinary pressure.
Other two, C and D containing increased amounts of oxygen.
January 25. The meat, which is the least altered in appearance, is
A. The pieces which are most altered are C and D.
EXPERIMENTS WITH SUPERHEATED FLUXES. 187
Without multiplying the experiments, I may give his results.
To quote his own words :
' Si nous envisageons d'ahord eelles de nos experiences qui
ont porte sur la diminution de pression, nous voyons d'une
maniere nette que dans I'air rarefie la putrefaction a ete nota-
blement ralentie et I'oxydation diminuee.
' Mais ces resultats n'ont rien de bien extraordinaire ; Ton
savait depuis longtemps que la putrefaction na pas lieu dans
le vide, et il etait tout naturel de penser qu'elle serait d'autant
moins active que I'air serait plus rarefie.'
Dr. Bastian does not always obtain these results (growth of
organisms) with infusions containing cheese, &c.' If he uses the
rind of the turnip in preparing the turnijD infusion spontaneous
generation may not occur ! At least such is Dr. Bastian's ex-
planation of his failure to get organisms in one or two instances.
An exj^eriment is also nan-ated in Dr, Sanderson's letter in which
the walls of the flasks v/ere thoroughly purified by heat before
the introduction of the fluid, in order to see whether the organ-
isms were or were not attached to the walls of the vessels. But
this experiment is completely nullified by the mode in which
the flasks were afterwards filled, for Dr. Bastian charged them
by ' bi'eaking off their points ' (they had been sealed when hot)
' under the surface of a neutral infusion of turnips and cheese,
freshly prepared for the puqiose without employing any of the
rind.' Here the previous purification of the walls of the vessels
was useless, for they were again soiled by the unpurified fluid
passing into the flask.
II. The second series of facts on which Dr. Bastian bases his
arguments . is, that certain solutions may be exposed in airless
and hermetically sealed flasks to a temperature of 270° to 275° F.
for 20 minutes, and yet that organisms may subsequently de-
velop in these flasks. Such fluids are chiefly strong infusions
of turnip rendered alkaline by liquor potassas.
Now I have already referred at length to the error that the
organisms may not be subjected to moist heat at all, and my
remarks apply here also. For 275° F. is not always sufiHcient
as dry heat.
But I would remark — and tliis may apply to some of the
' Sec letter by Ur. Biirdon-Sandcrson in Xuiiirc of Januar}- f), 187?..
188 SPO^TANJEOirs GENERATION.
first series of experiments — that in only one or two cases were
numerous and distinct bacteria found; and I have ventured
to think that in some of the other cases the deposit which
occiuTed was simply due to imperfect filtration, and contained the
forms described, these forms not having developed since the
introduction of the fluid into the flask. For, I would ask, if
they had developed anew, why was the fluid not full of them ?
Why was there only a slight deposit ? When organisms are
really present in cultivating fluids (as in some of Bastian's
experiments) they fill the fluid and render it turbid, often
with a scum on the surflice.
In some flasks various forms of organisms were found, and
fungi were present in the deposit at the bottom, more especially
when tartrate of ammonia was used. In some cases Dr.
Bastian mixed deal wood with the fluid, and found bodies like
vegetable cells, which were undoubtedly portions of the wood.
With regard to the fungi, Dr. Bastian has himself pointed out
that crystals of tartrate of ammonia, when old, generally con-
tain fungi in their interior.
Professor Huxley, in ' Nature ' for October 13, 1871, stated
that he had seen Dr. Bastian's experiments and preparations,
and expressed his belief that the organisms which Dr. Bastian
got out of his tubes were exactly those which he put into them,
that in fact he had used impure materials, and that what he
imagined to be the gradual development of life and organisation
was the simple result of the settling of these solid impurities.
For instance, he relates how on one occasion Dr. Bastian showed
him a specimen of a fungus developed spontaneously, which
Professor Huxley recognised as a fragment of the leaf of a
Sphagnum, and that it was so he ultimately, after great diffi-
culty, convinced Dr. Bastian.
On the other hand, it is but fair to Dr. Bastian to admit
that these settled impurities were not the only things which he
got, and that in reality in some cases undoubted organisms
developed. Dr. Burdon-Sanderson, in the letter just quoted,
says : ' The accuracy of Dr. Bastian's statements of fact, with
reference to the particular experiments now under consideration,
has been publicly questioned. I myself doubted it, and ex-
pressed my doubts if not publicly, at least in conversation. I
THEIR FALLACY. 189
am content to have established, at all events to my own satis-
faction, that by following Dr. Bastian's directions infusions can '
be prepared which are not deprived, by an ebullition of from
five to ten minutes, of the faculty of undergoing those chemical
changes which are characterised by the presence of swarms of
bacteria, and that the development of these organisms can pro-
ceed with the greatest activity in hermetically sealed flasks,
from which almost the whole of the air has been expelled by
boiling.' Cheese was used in most of the experiments which
Dr. Sanderson witnessed.
Among others who have been unsuccessful in repeating Dr.
Bastian's experiments may be mentioned Dr. E. Ray Lankester.
In ' Nature ' for January 30, 1870, he says, ' In numerous ex-
periments with turnip solution made by Dr. Poole and myself
recently in the Laboratory of the Kegius Professor of Medicine
of this University, we found that under the conditions given in
Dr. Bastian's book, no life was developed, a result contrary to
that obtained by him in 999 cases out of 1000.'
The fallacy of Dr. Bastian's experiments with saline solu-
tions was well demonstrated as long ago as 1 872 by Mr. Hartley.^
In no instance was he able to confirm Dr. Bastian's statements.
In his first experiment he made a fluid consisting of a 5 ^^er cent,
solution of tartrate of ammonia and phosphate of soda in distilled
water slightly acidified with tartaric acid. Several tubes were
filled with these solutions, and were heated for four hours to a
temperature of 1 50° C. They were afterwards kept at a tem-
perature of about 25° C. In none of them did any organisms
develop, but in some he found that a slight deposit occurred
which apparently was what Bastian had taken for a develop-
ment of organisms. On examination this deposit was found to
be inorganic, and to consist of silica alone. 'The disodic phos-
}»hate had attacked the glass, the silica dejjosited on standing,
and hence the jelly-like mass.' He adds further, in reference
to Dr. Bastian's use of magenta as a test for fungi, that mao-enta
also stains silica.^ Hartley does not consider these solutions
' The italics arc my own.
^ ProcrcdiiiiiH nf the lioijdl Socii'tji, vul. xx.
■' Dr. Frankland (Natiirr, January 11), 1871), in whose laboratory Dr. I'asfian
had performed these experiments, was not satisfied with the results, and
repeated sonu; of the experiments, lusinjr a soluficni of carbonate of ainuuiuia
190 SrONTAA\EOUS GENERATION.
capable of supporting life. In another set of experiments he
kept the tubes at a fluctuating temperature, which is another
of the conditions which Dr. Bastian considers favourable to
spontaneous generation ; but here also there was no develop-
ment. Similar experiments, which gave similar results, were
made with turnip infusions and with urine boiled and filtered
from mucus. After keeping such fluids in vacuo for a long
.time they were exposed to air, filtered through cotton wool, and
kept at fluctuating temperatures without any development ; but
when they were exposed to unfiltered air under the same
conditions, organisms rapidly developed.
Dr. Bastian ' says : ' The disruptive agency of heat is fairly
enough supposed by the evolutionists to destroy some of the
more mobile combinations in each solution — to break up more
or less completely, in fact, those very complex organic products
whose molecular instability is looked upon as one of the con-
ditions essential to the evolutional changes which are supposed
to take place.' With regard to this Hartley remarks, ' l^efore
granting such a supposition it would be necessary to know, first,
what are the " very complex organic products " of such peculiar
" molecular instability " existing in a solution of tartrate of
ammonia, sodic phosphate, acetate of ammonia, oxalate of am-
monia, in a solution of sugar and calcined yeast, in turnip
infusion, or any other putrescible liquid. My experiments show
that there is no such disruptive agency in a high temperature ;
that it does not influence the " more mobile combinations "
either in solutions of organic salts or vegetable infusions ; . . .
Dr. Bastian records the development of organisms in a liquid
heated as high as 153°C. ; yet the assumed "disruptive agency
of heat " is supposed to have influenced the results of Schwann
and Pasteur at a temperatm'e of 100° C. ! His experience is
contradictory to his own theory, and at the same time to the
experiments of others to which his theory raises objection.'
and pliospliateof soda, as had been done by Bastian in one of Ins experiments.
lie also states that the figure of eiglit particles and bodies which Dr. ]5astian had
mistaken for living organisms were merely 'particles of glass which had be-
come detached from the inner walls of the tube by the corrosive action of the
enclosed liquid at the high temperature to wJiich it had been exposed in the
' digester.'
' Nature, vol. i. p. 17G.
EXPERIMENTS WITH ALKALINE FLUIDS. 101
III. The third, unci indeed the only series of experiments
which can still be held to be worthy of consideration, are those
with alkaline fluids which, as is well known, are more difficult
to sterilise than acid or neutral fluids. Dr. Bastian states that
even though superheated, organisms may develop in them.
This difficulty in purifying alkaline fluids was long ago re-
cognised by M. Pasteur, and was attributed by him to imperfect
wetting of the organisms.
However that be. Dr. Roberts • has conclusively proved that
this is not a case of spontaneous generation, for he has shown
that while on the one hand an alkaline fluid is very difficult to
sterilise, yet as the same fluid without the caustic potash is very
easily rendered barren, and as the caustic potash is pure, if each
be sterilised separately and then brought together, without any
fresh access of dust, the fluid still remains pure ; in other words,
the caustic potash does not determine spontaneous generation.
He shows, in fact, that the potash acts by increasing the re-
sisting power to heat of the particles, which are the forerunners
of organisms — not by increasing the abiogenic aptitude of the
infusion.
Ten flasks were charged with unneutralised hay infusion. Five
of these were simply plugged with cotton wool, and boiled over the
flame of a lamp for five minutes. The other five were also plugged
Avith cotcon wool, but through the centre of each plug there passed
an hermetically sealed glass tube bent obliquely, and containing the
quantity of liquor potassse requisite to neutralise the fluid in the
flask. These tubes had been previously he;ited (after being charged
with liquor potassse and sealed) in oil up to 121"^ C. in order to
destroy any organisms they might contain. The flasks thus prepared
were then boiled over the flame for five minutes. At the end of a
fortnight their contents were unchanged. The tube was now broken
and the liquor potassaj mixed with the fluid. Not one fl isk ger-
minated ; at the end of two months they were still barren. But
although these flasks had not acquired the power to germinate, they
had accjuired the propcrtij of I'uahling frcaldij introducad germs to
survivi a boiliiuj heat, for when the flasks were un])lugged and
infected with ortUnary air or water and then replugged and boiled
five minutes, their contents in every instance germinated in a few
days.
' I'/nl. Tranx. 1874.
192
SPONTANEOUS GENERATION.
m
I can quite confirm Dr. Roberts's statements, for 1 have
used his method of boiling these fluids separately as an easy
mode of obtaining any required degree of alkalinity, and I have
never got any results which in the least support the view that
the addition of liquor potassa3 to any sterilised infusion will
make organisms develop in that fluid.
I have already mentioned Mr. Lister's method of procedure
preserving fluids. I have mentioned how successful this
was, and how all the difficulties as to tall and
small flasks, &c., were overcome simply hy
purifying the lualls and the air in the
jiasks ; hy taking care, in the introduction
of the ir)ipit7'e fluids, to avoid contact luith
the neck and lualls of the flask so purified
(above the level of the liquid) ; and hy
avoiding spurting or frotJting during the
heating of the fluid. By Mr. Lister's method
all sorts of fluids may be preserved and
transferred from one vessel to another, with-
out the development of any organism, with
the same certainty as without the occurrence
of any fermentative change (see Chapter I.)
Mr. Lister's method has removed a great
source of error in all these experiments, and
I am confident that if his instructions be
strictly followed out, the instances of difficulty in purifying
fluids will become fewer and fewer. During four years more
or less constant work at such experiments, I have only once
met with an instance of difficulty in purifying fluids. This case
will be alluded to presently.
The experiments of Dr. Roberts and of Prof. Tyndall • as to
the absence of fermentative changes in preserved fluids show
also the absence of organisms under the circumstances re-
ferred to. For their experiments were made with a view to the
determination of the question of spontaneous generation. And
in my own experience, in order to test various materials, as
' For later experiments than those (juoled at p. 24, rf wy., see Tyndall's
paper in the Philusoj)liical Transactions, vol. 1G7, 1S77, where some difficulties
which he experienced arc explained.
Fig. G6.— Dk. Ro-
bkrts's experi-
ment with al-
kaline eluids.
rRESERVATION OF MILK. 193
to whether they contained organisms or not, I have prepared
many hundred flasks of cucumber and turnip infusion, and
also many of milk, meat, &c., without in any instance obtain-
ing the slightest evidence in favour of abiogenesis. (The case
in which I found difficulty in preserving milk has been
already mentioned, and will be alluded to presently.) The
rapid souring of milk during a thunderstorm is looked on as
a change due to electricity. Accompanying this rapid souring
there is a rapid increase of bacteria. I have kept flasks of pure
milk for a year, through several violent thunderstorm-s, without
any change taking place in it, and without the appearance of
any organisms ; and at the end of the year the milk was quite
fluid and of normal character, though in a few days after the
flasks were opened (they were covered with cotton wool caps)
it had coagulated, become putrid, and contained numerous
bacteria.
194 SPONTANEOUS GENERATION.
CHAPTER X.
SPONTANEOUS GENERATION {concluded).
Facts with regard to unboiled flioids and tissues : Mr. Lister's facts with re-
gard to milk : my own experiments with animal tissues. Present state of
the question — Dr. Bastian's latest standpoint : Liebig's doctrine. Can or-
ganic molecules derived otherwise than from pre-existing bacteria give rise
to bacteria ? Firstly, there is nothing unreasonable in looking on these
particles as bacteria or their germs : seeds carried by air : excessive
minuteness of the germs of bacteria : Mr. Lister's experience with micrococci.
Secondly, there is no direct evidence that organic molecules not derived
from bacteria can give rise to bacteria: facts with regard to unboiled fluids
and tissues — conclusions from these facts : Paul Bert's experiments :
Cazeneuve and Livon : Pasteur : Dr. Bastian. Thirdlj', there is no evi-
dence that active organic molecules (chemical ferments, &c.) can resist
heat more than living things can : effects of heat on ptyalin, pepsin,
&c. : my own case of difficulty in sterilising milk : Wyman's fact as
to an alga living at 208° F.
With the great mass of evidence existing against the doctrine
of spontaneous generation, I should have no hesitation in casting
it aside. But much stronger evidence remains to be alluded to ;
viz., the behaviour of unboiled fluids and tissues when preserved
with certain precautions.
I have already referred to these experiments in a former
part of this work, and I may now state that where I have said
that fermentation was absent, I might equally well have said
that organisms were absent. I have mentioned that blood,
milk, and urine could be preserved, unboiled and unacted on
by chemical reagents, for an indefinite period, without under-
going fermentation, and, I may now add, without the develop-
ment of organisms.
Of these I may revert for one moment to Mr. Lister's
experiments with milk. Mr. Lister, in his attempts to obtain
pure unboiled milk, found that in none of his flasks did he
obtain lactic fermentation, but that in all but two (out of
UNBOILED FLUIDS AND TISSUES. 105
some 50 or 60 flasks) organisms of some form or other occurred,
these organisms being in many flasks of totally distinct kinds.
Now these results prove a great deal against the view of spon-
taneous generation. Two flasks had no organisms at all, there-
fore milk does not spontaneously generate organisms, does
not naturally contain them, has no inherent tendency to
undergo fermentation. Then milk which has never been in
the dairy does not undergo lactic fermentation ; hence the cause
of this fermentation is something coming from the dairy, not
some form of organic molecule present in the milk. Then not
only the fact that in two flasks no organisms developed, but
also the great variety which appeared in the different flasks
prove that they could not have developed de novo. For if
we have twelve flasks under the same shade, each containing
the same specimen of milk taken at the same time, under the
same conditions, any change occurring in one, due to something
inherent in milk, or due to some physical force or combination
of physical forces acting on it, would have occm-red equally
in all. But when we see one specimen remaining without
organisms, another having a pigment micrococcus, another
having bacteria, another fvmgi, and so on, we must conclude
that the appearance of these forms cannot be due to anything
inherent in this milk, but that it is due to something which
has entered the milk from without.
My own experiments on milk, referred to before, bear out
Mr. Lister's statements in every particular, and bring additional
evidence, in that they show that a much larger proportion of
flasks may be preserved if attempts be made to render the
particles in the air, or at least on the udder of the cow and the
hands of the milkmaid, inert by the use of carbolic acid or
other antiseptic.
Cazeneuve and Livon's experiments on urine have been
already referred to, and will be further discussed under the
head of fermentation, when they will be found to furnish
much additional evidence against the view of spontaneous
generation.
After referring to blood, uiilk, and u)ine, I also mentioned
the experiments on gi-ape juice by Van der Broeck, Pasteur, &.c.
and on vegetable ti^sues by Roberts, and I then pasi-ed on to
(> 2
lOG SPONTANEOUS GENERATION.
my own experiments on animal tissues. I described the
method I had employed, how the tissues were introduced into
and preserved in flasks containing cucumber fluid, and how
they remained unchanged, and, I miny now add, without any
development of organisms. That no organisms developed I
further ascertained by testing the beakers. By transferring, by
means of a pure syringe, a droj:) of their contents into a flask
containing pure cucumber or meat infusion, I found that no
organisms developed in the latter, proving that none were
present in the former. That organisms would have been
found by this method, if they had been present in the fluid, is
shown by the fact that, if bacteria were injected into the
animal immediately before death, they were found in the
beakers and in the flasks. I have also stained the granular
matter present in these beakers with methyl violet, according
to Koch's method, and have failed to find any organisms (see
Plate V. fig. M).
From all these facts it may therefore be regarded as certain
that organisms do not originate spontaneously, in the sense
formerly held, under any circumstances, but that they appear
in animal or vegetable fluids and tissues as the result of the
entrance of solid 'particles into these after their exit from the
living organism. That the question has narrowed itself to
this, that it is now no longer a question of spontaneous origin
of organisms in fluids which have been severely boiled, but that
it is a question as to whether some of the 'particles which get
into fluids and which resist heat may not be organic molecules
not necessarily derived from pre-existing bacteria, or whether
they are bacteria or their germs, is evident from what has gone
before, and at last Dr. Bastian has formulated similar views
in his paper in the 'Nineteenth Century 'for February 1878.
He says : —
' The modern opponents and supporters of the doctrine of
spontaneous generation have always been principally concerned
with two sets of problems, (1) As to the nature of the material
in the air, the access of which is so apt to induce fermentation
in suitable fluids ; (2) As to whether some degree of heat
below 212° Y. can be proved to be always sufficient to destroy
FINAL STANDrOlXT OF THE THEORY. 107
the life of different kinds of living matter in the moist state,
but especially that of bacteria and fungus germs.
' In regard to the first set of problems it has been generally
agreed for some time that the air contains some germs of living
organisms, but that what proportion these bear to the much
more bulky, and probably more numerous, organic particles and
fragments resulting from the breaking up of previous living
matter of various kinds, is uncertain. It has also been gener-
ally admitted that any living organisms or germs which chanced
to fall from the air into suitable fluids would initiate fermenta-
tion or putrefaction therein. The question really requiring to
be solved has always been (though it has not been uniformly
recognised) whether mere organic debris from the air, either in
the form of particles or of larger fragments, could or could not
also bring about such changes in suitable fluids.'
This view corresponds very closely with the position which
Liebig was ultimately driven to take up on the subject of fer-
mentation, and Dr. Bastian says : ' It is Liebig's doctrine which
legitimately suggests the doubt above mentioned in regard to
the possible potencies of atmospheric particles other than actual
germs .... If it has been shown that the appearance and
increase of the lowest living particles are always a coiTelative of
these processes (fermentation and putrefaction), Liebig's view,
if it be true at all, must be true for the tuliole of the -processes '
which are essentially included under the term fermentation.'
It will thus be seen* that Liebig's theory and Bastian's recent
views stand or fall together, and that the facts against one tell
equally against the other. Just now I shall only deal with
Bastian's views, but their intimate relation with Liebig"s theory
must be borne in mind, so that the full significance of the facts
opposing the latter may be recognised in their bearings also on
the former.
Dr. Bastian later on says : ' I go no further than to say that
in the present state of the evidence bearing upon the subject I
regard the hypothesis of spontaneous generation as the most
logical and consistent interpretation of the facts which are at
present known.' We must therefore consider what the evidence
on this subject is, and whether there are any grounds for accept-
' Tlie italics are miue.
108 SPONTANEOUS GENERATION.
ing the theory that the organic molecules which give rise to
bacteria originate from matter other than pre-existing bacteria,
rather than the view that they are directly derived from pre-
existing bacteria, in other words, that these particles are
nothing more or less than bacteria or their germs. .
I. Firstly, there is nothing unreasonable in looking on
these particles as bacteria or their spores ; indeed, Dr. Bastian
admits that some of them are derived from bacteria. But if
some, why not all ? Because some resist heat more than others ?
We shall return to this presently.
We know that the seeds of plants are often wafted by the
air, and this is more likely to be the case the lighter the seed,
and therefore it is generally admitted that the seeds of fungi,
large or small, are carried by the air. Indeed, both Pouchet
and Pasteur found and recognised the spores of fungi in air
dust.'
Further, bacteria propagate by fission in fluids, that is to
say, one bacterium develops from another. This process has
been often observed. Then, again, some forms of bacteria have
been found to produce spores, notably forms of bacilli. Thus
the spores of Bacillus anthracis have been fully described by
Koch, and still more recently the occurrence of small sporules
of excessive minuteness has been described by Ewart.^ Ewart
has also asserted that other forms of bacteria, especially of
Spirillum, produce spores in like manner. If then in fluids
bacteria always grow from bacteria, if some bacteria like fungi
produce spores, why refuse to believe that the particles in the air
which give rise to bacteria are these organisms themselves or
their spores, just as the particles which produce the larger fungi
have been shown to be their spores ? The excessive minute-
ness of the bacillus spores renders them difficult of discernment
in fluids under the microscope. When dried and shrunk we
' In December 1880, having collected a quantity of laboratory dust by
aspiration of the air through gun cotton for several weeks, I dissolved the
gun cotton in ether and alcohol, and collected the dust on a glass slide : this
dust was stained with methyl violet according to Koch's method (see Chapter
XII.), and a drawing of it is given in Fig. 35, Plate V. It will be seen that
one or two bodies are present which are indistinguishable from bacteria and
micrococci, and these bodies have been stained by the methyl violet.
'^ Se3 Praccedings of the Royal Society, 1878.
SPORES CARRIEU BY THE AIR. 1L»0
should expect them to be hardly visible ; and if the spores of
such large organisms as Bacillus anthracis are hardly visible,
how much less likely are we to find the spores of organisms which
themselves can be seen only with difficulty ? It seems to me
that it would be a very extraordinary thing if in the case of
these minute organisms alone, the particles which gave rise
to them were not derived from pre-existing forms.
But when we find that under certain circumstances the
same form of organism originates from these particles, as we
should expect were the latter spores, the case is made still
stronger. This latter fact will be more evident w^hen we come
to consider the relations of these bodies to fermentations, but
I shall here mention one experience related by Mr. Lister.' In
some experiments on the growth of a fungus in urine, a form of
micrococcus, which he terms Granuligera, constantly appeared in
the urine. He found that these were really organisms, from
an opportunity which he had of watching their growth. He
then says: — 'About this time, my study suffered from an epi-
demic of Granuligera. I could not now perform the same
experiments with the same success as in the first instance : any
that I tried was sure to be followed by the development of this
pervading organism. I eluded it, however, by continuing the
investigation in a room at the top of the house, which had been
for a considerable time unoccupied. Here the results of the
experiments corresponded with those originally obtained in the
study.' In this experiment there cannot be the slightest doabt
that the particles which gained access to the cultivating fluids
were these micrococci or their spores, if they have any. It could
hardly have been some form of organic molecule not derived from
these organisms which always gave rise to exactly the same forms.
Such are some of the facts which show that it is not un-
reasonable to look on these particles as bacteria or their germs ;
and Dr. Bastian, as I have already said, admits that some of the
particles are derived from pre-existing bacteria.
II. Secondly, not only is it not unreasonable to regard these
particles as bacteria or their germs, but there is no direct evi-
dence whatever that organic molecules not derived from bacteria
can give rise to bacteria.
' See Transactions ofihc Royal Sonrty of Edinhuryh, 1875.
'_>UU SPONTAXEOUS GENERATION.
Look at all the facts I have brought forward as to unboiled
fluids aud tissues. I have shown that the most diverse organic
fluids and tissues may be preserved for an indefinite period,
without the development of organisms so long as the particles in
the air and on surrounding objects are excluded. And yet
these substances are full of organic molecules derived from
previously living structures.
Cut a piece of liver, kidney, muscle, or other tissue from a
healthy animal not yet dead, and place it, with precautions to
exclude atmospheric dust, in a flask containing cucumber solu-
tion. Here you have at first in the fluid and in the tissue living
cells and living organic molecules — and we know, as in the case
of muscles, that life may be retained for some time — and yet no
organisms appear. These living organic molecules of all kinds do
not give rise to bacteria or any other form of life — they die.
Again, when the same specimen has stood for some time,
we have a highly putrescible and fermentescible material con-
taining dead organic molecules of all kinds ; and yet no life
appears, and such flasks may be kept for an indefinite time
without the development in them of life.
But again, these organic molecules are not only dead, but
decaying. They undergo slow oxidation — what Liebig has
termed eremacausis. And yet they do not develop into or
induce the appearance of living forms.
Organisms only develop in these fluids and tissues when
bacteria or their germs or when atmospheric dust is introduced.
Whence, then, are the hy|3othetical organic molecules derived ?
If they do not develop life in such fluids as cucumber or meat
infusion, or in meat itself, under the conditions described, how
is it that they come to do so after having floated through the air ?
Is it that they have acquu-ed new ijroperties in the air, or is it
that the organic molecules (not derived from pre-existing bac-
teria) which, falling from the air into the fluids or on the tissues,
give rise to living forms, are specially manufactured in the air ?
One or other of these conclusions must be accepted, and I say
they are both equally untenable.
And when I come to speak of the relations of organisms to
fermentations, more especially to fermentations occurring in
wounds, I shall bring forward evidence of a similar character.
EVIDENCE FROM UNBOILED TISSUES. L^Ol
Thus I take flasks containing pure, highly putrescible fluids,
such as meat or cucumber infusion, or milk, and I introduce
into them pus, blood, or serum from wounds, and place them
under the most favourable circumstances for the development
of organisms, and yet no organisms develop. The same
reasoning applies here as in the case where larger living masses,
as liver, have been introduced into similar infusions. On the
other hand, if bacteria or micrococci are present in the dis-
charge (and I confirm this by microscopical observation), organ-
isms develop in these flasks, and organisms of precisely the
same morphological characters as were present in the original
discharge.
But let us glance for one moment at Paul Bert's work.
He subjects such substances as saliva, pepsine, myrosin,
emulsin, &c., to high pressures, say twenty atmospheres, and
he finds that when the normal pressure is restored, these
substances have not in anyway suffered, as regards their ferment-
ing power.
On the other hand, he places putrefying or fresh meat under a
similar pressure, and after restoring the normal pressure, he finds
that if he excludes fi'esh atmospheric particles, putrefaction is
in the first case arrested, and in the second, never takes place.
Organisms never again develop unless fresh dust is admitted.
From the first set of experiments we see that organic mole-
cules when they have any power of acting are not deprived of
it by high pressure, while from the second we learn that under
similar circumstances life is destroyed, and no new life appears.
And yet this cannot be because the power of generating organ-
isms, which organic molecules are supposed by Dr. Bastian to
possess, has been destroyed by the high pressure ; for, as we
see in the first experiment, dead organic molecules, as distin-
guished from living ones, retain their powers even under this
pressure. The organic molecules, then, which originated the
bacteria were living molecules, but tiot imerely any living
molecules, as is evident from the liver experiments, hut living
molecules derived from 'pre-existing bacteria.
Then, again, Cazeneuve and Livon's experiments, which will
})e detailed presently, prove exactly the same points. They
show that it is not organic nioloculos in urine or in the wall of
'202 SPONTANEOUS GENERATION.
the urinary bladder which originate bacteria, but that it is
organic molecules derived from the dust of the air ; in other words,
derived from pre-existing bacteria.'
All the proof which Dr. Bastian attempts to adduce on this
point is to bring forward the opinions of several eminent meta-
physicians as to the first origin of life on this globe. But with all
respect for these great minds, I do not see one particle of proof,
but merely metaphysical speculation, in the extracts quoted.
Dr. Bastian removes the question to the first origin of life, and
at once throws aside the creation view as untenable. I do not
intend here to enter on this question, but I for one am not
prepared to go so far.
III. Thirdly and lastly, we have no evidence that active
organic molecules can resist heat more than living things can.
Let us take the so-called ' unformed ' ferments, which consist
of active organic molecules. The action of saliva on starch is
favoured by a temperature of from 35° to 40° C, but its amy-
lolytic activity is permanently destroyed by heat, even below
the boiling point, applied for a few minutes.
The same is true of gastric juice ; 'at temperatures much
above 40° or 50° C. the action of the juice is impaired. By
boiling for a few minutes the activity of the most powerful
juice is irrevocably destroyed.' (Foster.) And so with pan-
creatic juice, &c.^
I have previously discussed at length the errors in experi-
ment and observation which have led to the belief that or-
ganisms can develop in materials subjected to a m.oist heat for
a sufficient length of time. And I have quoted Dr. Eoberts's
refutation of the experiments with alkaline fluids.
1 stated on page 193 that I had only met with one in-
stance, in an exceptionally long experience, of difficulty in
sterilising an organic fluid. This fluid was milk got from a
particular shop near the Strand. When I got fresh milk from
' Again, Pasteur by his experiments of opening vessels in different situations
has distinctlj' shown that all particles of dust do not cause development of
organisms ; for undoubtedly organic debris did get into all his flasks, esijecially
those opened outside, and yet it was only when certain special particles
entered that organisms developed.
2 Compare also Bastiau's views on the Disrvpticc At/piici/ of Ilcaf, referred
to at page 190.
RESISTANCE OF BACTERIA TO HEAT. 203
a dairy in Albany Street, I had no difficulty in rendering it
barren by immersion in boiling water for a few minutes.
But the milk from the shop near the Strand has been immersed
in boiling water even for three hours, and yet organisms deve-
loped in it. It is to be noted that in all cases the bacteria were
identical in form and in the effect which they produced on the
milk : they were a form of long bacillus. Now here we had
some particle which got into the milk and caused a special
change in it, and a constant development of a particular and
easily recognisable form of organism — an organism which, more-
over, has been found by other observers to resist heat, and
especially dry heat, in an extraordinary manner. Is it reason-
able to suppose that the particles which gave rise to these
organisms were organic molecules derived, goodness knows from
what, or specially manufactured in the air of this shop ? Or is
it not more reasonable to suppose that the air was infected
with some form of bacterium or its spores, just as in Mr.
Lister's case with Granuligera, and that this special form or
its spores possessed the same resisting powers which it has
been found to have in other parts of the world. For I may add
that the spores of bacilli are stated by all who have investigated
the subject to be possessed of extraordinary resisting power.
After all it is not a matter of great surprise that an
organism should resist a heat of 210° F. (that has been ascer-
tained by Mr. Lister to be the temperature of milk immersed
in this way), for Prof. Jeffries Wyman tells us of a form of alga
which lives normally in water the temperature of which is
208° F.'
With this great mass of evidence, and I could have multi-
plied it manifold, I do not see that there can be grounds for
' Doy^res found tliat dried Tardigratlos were not destroyed till the tem-
perature reached 140'^.
Payen showed that thcspores of oidium aurantiacum did not lose tlieir ger-
minating power till the temperature readied 140° C.
Milne-Edwards has found tliat dried organisms could resist a \Qry high
temperature.
Instances of great resisting power of seeds to heat have been brought
forward by Tyndall and others. Mr. James Sanderson, of Galashiels, tells me
that in some specimens of wool obtained from South America, seeds of
medicago are present, which develop even after the wool containing them has
been dyed— ?.^. after the}' have been subjected to \ n, longed boiling and to the
action of various clicmical sulistanccs.
204 SPONTANEOUS GENERATION.
any longer retaining the view of spontaneous generation. It
wonld just be as sensible to suppose that in the impregnation
of the ovum of higher animals it is not the spermatozoa, but
some organic molecule accidentally introduced at the . same
time which causes the development of the ovum, as to suppose
that it is not bacteria or their spores but some organic molecule
manufactm'ed in or specially altered by passing through the air
which produces bacteria in organic fluids and tissues.
'VITAL' AND 'CHEMICAL' FERMENTATION. 205
CHAPTEE XL
RELATION OF MICRO-ORGANISMS TO FERMENTATION.
Summary of what has preceded with reference to fermentation. Relation be-
tween ' vital ' and • chemical ' fermentations : theories of fermentation.
Liebig's views. Alcoholic fermentation : PasteitrKt experiments and concln-
shns. Resume. Butyric fermentation. Formation of pigment by bacteria
Schroeter : Colin. Viscous fermentation. Lactic fermentation : Pasteur:
Lister. Other fermentations, especially the putrefactive : Lemaire ; Caze-
neuve and I.ieon : Paul Bert. Conclusions.
We must now pass on to the relation of these bodies to fermen-
tations, and I will here merely indicate the chief points without
entering into a discussion on the subject And first, I may .say
that it is now admitted by Dr. Bastian, s well as by other
observers, that organisms are present in all fermenting fluids.
This statement was formerly denied, on account of the imperfec-
tion of the methods of examination.
We have already seen in the iirst part of this work that the
cause of fermentation in organic substances was the entrance
into them of solid particles held in suspension in air. We have
also seen that the cause of the development of organisms in
fluids and tissues was the entrance into them of particles sus-
pended in the air. We also know that in all fermentations
organisms are present, and that in the absence of organi.sms no
fermentation occurs. What more likely, then, than that the
particles which cause fermentation, and the particles which
originate organisms, are one and the same ? that in fact the
fermentation of a fluid is the result of the growth of organisms
in it ?
The process in these ' vital' fermentntions may be brouo-lit
into the same category as that in fermentation by the 'un-
formed ' ferments, if we sn])])<)S(» that the immediate cause of
the chemical change in the fujiner instance is some chemical
20G FERMENT A TION.
substance resembling ptyalin, pepsin, &e. No doubt there is
this difference between ordinary fermentations and those due
to a chemical substance, that in the former case the ferment
itself increases in quantity. This difference would, however, be
easily reconciled if we were to suppose that each organism was a
former of the ferment, even though to an extremely limited
degree. The process in these ' vital ' fermentations, of which we
may take the alcoholic as an example, would then be the same as
in the so-called chemical fermentations. Thus, to speak of the
case of the saliva, ptyalin is not a chemical compound formed
spontaneously, nor is it the result of any sort of double decom-
position ; it is a substance formed as the result of the vital
action of certain living cells. According to the view under
consideration, the alcoholic ferment would be likewise the pro-
duct of the vital action of certain cells, the yeast cells. The
ptyalin itself has not the power of self-multiplication, but the
cells which form it produce it continuously; the ferment of
alcohol would not have the power of self-multiplication, but the
cells which form it produce it continuously. This explanation
agrees completely with the contrast between the effects of
ptyalin on starch, and those of yeast on sugar. The ptyalin is
more or less immediate in its effect. It is a very active formed
ferment. The yeast acts slowly because the ferment is only
produced as the plant grows. Hence the explanation of the
rapid action of the one and of the progressive action of the other.
The apparent self-multiplication of the ferment in the alcoholic
case would be due to the fact that the producers of it are free —
float freely in the fluid - and hence ultimately no drop of it can
be taken which will contain sufficient ferment to act without
the ferment-producers being also present. In the case of the
saliva, the ferment-producer is fixed, and the ferment is obtained
alone and apart from its originator, hence it does not multiply.
The same causes which arrest the production of ptyalin arrest
also the alcoholic fermentation, for they destroy the living
cells which form the ferment.
The case of emulsin would be exactly the same as that of
yeast. The emulsin itself does not multiply, but the seed, the
producer of it, does. Sow a seed of the bitter almond, and there
sjjrings up a phnt bearing numerous seeds, numerous producers
THEORIES OF FERMENTATION. 207
of emiilsin. Sow a yeast cell, and there follows the growth of
numerous yeast cells, each producing a quantity of the ferment.
Considerable support is given to this view by the experi-
ments of Musculus, on the mechanism of the ammoniacaL
fermentation of urine. This has been shown to be due to the
growth of an organism in the urine (Micrococcus urese, Cohn).
Musculus' demonstrated that, by adding absolute alcohol to am-
moniacal urine, a precipitate was obtained which could be filtered
and dried. This precipitate transformed urea into carbonate
of ammonia. Its power was destroyed by exposure to a tem-
perature of 80° C. This soluble ferment is a secretion of the
micrococcus urese.
According to another view it may be that the organisms,
while living in various substances, feed on them, and the pro-
ducts of the fermentation may be either the portion of the food
which has been rejected by them, or products formed in and
excreted by the organism.
Or it may be that, as Pasteur holds, the cause of the fer-
mentation is not the production of a ferment but the breaking
up of the chemical compounds by the growing plants in the
search for nutriment, more especially for oxygen. It is quite
clear that there must be such a breaking up. Or, again, it may
be that in this breaking up of the organic compounds some of
the molecules may rearrange themselves and form a ferment,
and the presence of a ferment of this kind I consider the best
explanation of some of the special fermentations, though I
incline to hold that the ferment is excreted by the cell itself.
It is, however, probable that in different fermentations the
process occurs in different ways. Thus in the pigment fermen-
tations, as will be seen, the second is probably the correct
explanation. The point of importance is that in any case
there is nothing unreasonable in associating these changes
with the growth of living cells ; in fact all analogy points to
such a relation.
The only other theory which is tenable in the presence of
the facts stated, would be that the ])articles which cause fermen-
tations are not the same as those which give rise to the growth
of organisms, but that they are bodies which have only the
• 3Iagni2i, Jiaetrria
208 FERMENTATION.
power of causing fermentation, and are possibly either sub-
stances in a state of decomposition or special ferments. But
then it is inconceivable that fermentation and the development
of organisms should always be associated, or that organisms of
the same form, e.g. the yeast cell, should always be present
in the same fermentation. Supposing this view possible, we
must assume that there is a special organic molecule for each
fermentation, for otherwise we could not explain the occurrence
of lactic fermentation in one flask, putrid fermentation in
another, pigment fermentation in another, &c., all the flasks
containing the same specimen of milk having been filled at
the same time and kept under the same conditions.
Liebig originally propounded the view that fermentation
was a change in organic fluids and tissues, set in motion by the
access of oxygen or of bodies in a state of decomposition. He
at that time regarded organisms as quite accidental. He sup-
posed that when organic matter was exposed to the air, it
underwent a slow process of oxidation which he termed ereraa-
causis ; and that this change, communicating itself to other
molecules, caused them to break up or putrefy. In the presence
of the facts stated as to the relation of dust to the fermentation
of boiled and unboiled fluids, Liebig modified his views, and
in his last publication he admitted that the yeast plant was
in some way or other connected with the alcoholic fermentation,
but he thought that the relation between them most frequently
consisted in this : — that when the yeast cells died, they decom-
posed, and that the chemical change thus set agoing was propa-
gated to the sugar, and caused it to break up into alcohol and
carbonic acid.
That Liebig's theory of decaying inatter is incorrect Avill be
seen by a consideration of the facts mentioned on pages 200 and
210. Liebig was not latterly, however, absolutely opposed to the
acceptance of the doctrine that living organisms are initiators
of fermentative changes. On the contrary, to quote from Bastian,
' he slightly widened his views after the coiTelation of organisms
with fermentations had become established, and endeavoured to
show that the admitted actions of living units in initiating fer-
mentations were but other exemplifications of his general
doctrine, that fermentations are induced by certain communi-
ALCOHOLIC FEIiMENTATION. 209
cated molecular movements, sometimes emanating from organic
matter in a state of decay, and sometimes resulting from the
vital processes of living units.'
Had Liebig left out the part of the view which holds that
fermentations may be caused by movements, ' sometimes
emanating from organic matter in a state of decay,' there would
not have been much to find fault with. His theory would then
have been merely another way of viewing the mode of action of
these living bodies.
Certain definite facts are known which show that organisms
do take part in certain fermentations, while I have already
disproved Liebig's view that decaying matter has any power
of causing these changes. The facts to which I am about
to allude, when taken together with the constant presence of
organisms in other fermentations of the same class not yet in-
vestigated, render it, to my mind, certain that living organisms
are, probably in one or other of the ways indicated, the causes
of these chemical changes.
A Icoholic Fev)iieittatioit.
The first case of fermentation which was studied, and about
which most is known, is the alcoholic fermentation. The facts
and experiments on tliis subject are now so universally known
that it would be superfluous for me to do more than summarise
them here.
The yeast plant (Toriila cerevisice) is always present in a
state of vitality during the alcoholic fermentation of sugar.
If yeast be raised to the temperature of 60° C, at which
temperature the cells die, the fermentation of sugar no longer
occurs. Here the cells are dead, and if Liebig's view be
correct, that dead cells, not living ones, are the cause of the
fermentation, the process ought still to go on.
The juice of the grape has no spontaneous tendency to
imdergo fermentation, as shown by the exijeriments of Van der
Broeck, S:c., formerly mentioned, and by the following experi-
ment narrated by Pasteur. In a flask of the form shown in Fig.
68, A) the neck (a) of which w^as drawn out to a fine point,
Pasteur boiled water which had ])een used to wash the outside
p
210
FERMENT A TIOX.
of a grape, and which therefore, according to other experiments,
contained abundant causes of the alcoholic fermentation. This
point (a), which had been sealed, was heated, and plunged
through the heated skin of a grape (Fig. 68, B). It was then
broken in the interior of the
grape, and, by causing a diminu-
tion of pressure inside of the
flask, a drop or two of the juice
was sucked into the boiled water.
(The diminution in pressure was
thus obtained. After heating the
walls of the flask with the hand or
a lamp, the orifice of the bent
neck (Fig. 68, A, 6) was sealed.
When the point of a was broken
off in the interior of the grape a
little juice passed into the flask.)
The orifice a was then sealed?
and the orifice h opened. Here, then, he had in the flask unboiled
grape juice, oxygen, water, dead organisms, and organic mole-
FlG. C7.— TOKULA CEREVISIiE.
(AFTER Pasteur.)
3 A
Fig. G8. — Pasteur's experiment on unuoiled grape juice.
A, tlic flask cmployorl. a. The neck v/hicli is represented in B a-s plunj^ed into the grape. 6, Tlic
orifiof of the lient neck at first scaled till the grape juice has been introduced and tlien ojjencd
and left open. (From Pasteur.)
cules, and yet no alcoholic fermentation occurred. This and
other experiments' led Pasteur to the following conclusions : —
' Sue Etudes mr la Biire.
ALCOHOLIC FERMENTATION. 211
'The boiled juice of the grape never ferments when kept in
contact with air which has been deprived of the germs suspended
in it.
' Boiled grape juice ferments when a very small quantity of
water is introduced, in which the surface of the grapes and of
the branches of the vine have been washed.
' Grape juice does not ferment after the introduction of this
water if the latter has been previously boiled and cooled.
' Grape juice does not ferment when a small quantity of the
juice taken from the interior of a grape is introduced.'
Pasteur further shows that the apparently spontaneous com-
mencement of fermentation in these fluids is due to the
existence of spores of the torulse in the air, though they are
not, as a rule, present in great abundance. He also brings
forward experiments to show how other fungi, such as Myco-
derma aceti, can, when there is too little oxygen present, cause
the splitting up of sugar into alcohol.
.Seeing, then, that boiled and unboiled grape juice may be
preserved unaltered in presence of air which has been heated,
or in some way or other deprived of its dust, it is quite evident
that alcoholic fermentation is not a spontaneous decomposition
nor one which can be brought about by the action of the gases
of the air alone. Seeing, also, that the yeast plant is alwavs
])resent when fermentation is going on, that anything which
destroys the vitality or interferes with the growth of that plant
arrests or interferes wuth the alcoholic fermentation, and that
the introduction of dust which does not contain the torula
cells is not rccompanied by the alcoholic fermentation but by
some other change, we must conclude that the particles which
fall into fluids and give rise to alcoholic fermentations are in-
timately associated with the particles which give rise to yeast
cells, and further that they are living particles subject to the
same laws as the yeast cell itself. And seeing, further, that other
]>lants when living under certain conditions are also capable of
giving rise to the alcoholic fermentation, we must conclude that
this change is a process due to changes in living tissues, that,
in fact, the fermentation is the result of the life of these cells
and ])lants, and that, therefore, the i)articles which, falling into
iluids, give rise to tlic Toiiila cerevisia', and those which give
V 2
212
FERMENT A Tl ON.
rise to alcoholic fermentations, are one and the same ; in fact thai
the growth of the yeast cell is in some way or other the cause
of the alcoholic fermentation.
Butyric Fermentation.
Pasteur has also brought forward evidence of a similar
nature as to the butyric fermentation. The organisms which
produce butyric fermentation are bacilli [Bacillus stibtilis, Colm),
which apparently live without
free oxygen, and indeed are
killed by it, and which when
cultivated in various fluids,
even in Pasteur's solution,
cause butyric fermentation in
all (see Fig. 69 and also Fig.
64).
Formation of Pigmeoit by
Bacteria.
Fig. 69.
-Bacillus subtilis,
(after Cohn.)
Striking facts as to the
*'°^' association of a definite chemi-
cal change with the presence
of organisms of a definite form were brought forward by Cohn
and Schroeter with regard to ' pigment bacteria.' '
They showed that while many forms of organisms could
grow on such soil as boiled potatoes, yet a definite pigment
was produced only when one particular form was present.
These organisms gener.dly belonged to the group of ' micro-
cocci,' though sometimes pigmentation was caused by bacteria,
as in blue pus (see Fig. 70).
These pigments were sometimes scarlet, sometimes blue,
sometimes soluble, sometimes insoluble ; and when a variety
of soils were inoculated from an individual specimen, the same
colour, with the same chemical and other characteristics and
the same organism, always resulted. Not only might these
pigment bacteria grow on boiled potatoes, they could flourish
Beitragc zur Biologic dcr Fjlanzim.
FORMATION OF PKrMENT BY BACTERIA.
218
Fig. 70.— Pigment producing
organisms.
A, Micrococcus prodigiosus. B, Micrococcus
fill vis. C, Bacillus ruber.
on cheese, meat, white of egg, bread, starch, &c., the same
2)igment being invariably produced.
The conditions under which this pigment appeared were
exactly those which were most favourable to the life of the
organisms, while those in
which it was absent were those
in which the organisms could
not develop.
Schroeter concludes from his
investigations that these ex-
amples show what a manifold
series of pigments may be
produced ' by bacteria and bac-
teridia.' He adds that the or-
ganisms which form them can
often be recognised as distinct
owing to the difference in the
pigment produced ; the organ-
isms which form the various
pigments being often also dis-
tinctly separable by different morphological characters, and
tlie different pigments behaving differently with reference to
chemical reagents. He considers that it is not unjustifiable to
hold that each separate pigment is formed by a distinct specific
organism.
Schroeter points out that the pigments are definite chemical
substances formed by the bacteria from organic, albuminous
materials, and tliat the process is therefore quite analogous to
the formation of alcohol by the yeast plant or of lactic acid liy
other bacteria.
Cohn farther found that these same organisms developed
readily and produced tlie same pigment in artificial cultivating
fluids contarninr/ ammonia, and a carhonate, hut no trace of
albumen. Once obtained in this fluid tliey could be propagated
indefinitely, the same pigment being constantly ])roduced.
Tn this instance we have an exam])l(' of a definite change
bi'ought about by the growth of a dfliiiitc form of organism.
No spontaneous change ever occurs in Colm's artifu-ial fluids
resulting in the formation of these pigments, and yet as soon
214 FFAtMENTATIOX.
as these organisms, which are associated with definite pigments
when growing on albuminous soil, are introduced into these
mineral solutions, the same pigments appear. That in the latter
case the pigment is formed by the bacteria is evident, for it is a
complex organic substance, closely related to the aniline colours,
and yet in this instance it is derived from a few inorganic salts.
It is therefore a substance formed by the living plants, and, as
before remarked, there is nothing remarkable in this production
of pigment by living cells. It is only what is constantly occur-
ring in many animal and vegetable cells, and in the latter it is
formed from inorganic compounds. Indeed, it would be against
all chemical experience that by any purely chemical process a
complex organic compound would be so readily built up from a
few inorganic compounds of a very simple kind.
These facts absolutely prove that the pigment fermentation
was the result of the life of the organism, for the pigment
must have been built up by it and could not have originated
from chemical changes projoagated to the fluid. If then Dr.
Bastian is correct in his opinion that ' Liebig's view, if it be
true at all, must be true for the tvhole of the processes which
are essentially included under the term fermentation,' these
facts alone overturn Liebig's theories.
Viscous Fertnentation.
Similar facts are known with regard to the viscous fermen-
tation of sugar. This is a transformation of sugar into gum
mannite, and carbonic acid, and results in the formation of a
viscid, ropy fluid. Pasteur found that organisms of a special form
were present in such instances, and these organisms when sown
in Pasteur's solution always caused this viscous fermentation.
The kind of proof is exactly the same as in the other instances
of fermentation, and need not be repeated here.
Lactic Fermentation.
An instance in which the causal relation of organisms to a
fermentative process is absolutely demonstrated is the lactic
fermentation of milk.
This fermentation was investigated several years ago by
LACTIC FERMENTATION. -215
Pasteur, ' who showed that it was exactly analogous to the alcoholic
fermentation, and that it was caused by a special organism. On
examining fluids which were undergoing lactic fermentation
he observed that minute round or oval cells were constantly
present. These organisms when transferred to fluids capable
of nourishing them always produced lactic acid. To prove
that these organisms were the cause of the fermentation he
made a decoction of yeast, to which he added sugar and chalk.
When they were sown in this fluid lactic fermentation oc-
curred, resulting in the formation of large quantities of calcium
lactate.
This fermentation has of late been more fully studied by
Mr. Lister, and as his experiments bear on the whole subject of
fermentation, I shall refer to them somewhat at length.
As I have previously mentioned, Mr. Lister ^ found that milk
had no inherent tendency to undergo the lactic fermentation ; in
fact, unless it was brought into a dairy or into contact with
dairy vessels or workers, all sorts of fermentations would occur
rather than the lactic. On examining milk undergoing lactic
fermentation he found that an organism of a definite and easily
recognisable form was constantly present, while in milk which
was not brought into the dairy, and which did not undergo
lactic fermentation, this form of organism was absent.
' This organism is a motionless bacterium occm'ring most
commonly in pairs, but frequently in chains of 3, 4, or more indi-
viduals, each segment being of somewhat rounded form, more
or less oval, with the long diameter in the direction of the
length of the chain, and often showing, on careful focussing, a
line across their central part, indicating transverse segmenta-
tion. They vary in diameter. . . full-sized specimens measur-
ing about y7rt¥^^^^ inch.'
The question now arose, Was this organism, so constantly
present in milk which was undergoing the lactic fermentation,
the cause of that change or not? Was some other bacterium
the active agent, or was it some hypothetical organic molecule ?
Mr. Tiister solved these jjoints in the following beautiful
manner. He prepared a series of flasks containing milk which
' A II lift lis tic Chilli rf lie P/ii/ti., vol. lii. ]). III".
- Triinaarliiinii iif ihr Pitniohuprtil Snrirfi/ of Linii/iin, 1878.
1^10
FERMENT A TION.
had been boiled. These were kept for some time till it was
certain that the milk had been rendered sterile. Having cal-
culated how many of these oval organisms were present in a
given quantity of fermenting milk, he diluted this milk so as to
have only one bacterium in a definite quantity {e.g. yJ,oth of a
minim) of the fluid, su})posing that the bacteria were equally
diffused throuirhout it.
Fig. 71.— r.ACTEiuuM lacti-;
IN PAIKS AND CHAINS.
In one cliain the component cells arc
uncU-roroing division. (After Lister.)
This was rlone in the following manner :— ' By means of the syringe
already described ' (one graduated to the y-i-^th of a minim) 'one or
more hundredths of a minim could l>e
measiu'ed with precise accuracy; and I
found that J^th minim exactly occupied
a circular plate of thin covering glass,
half an inch in diameter, so that when
such a drop was placed on a glass slide,
and a cover glass of the size mentioned
and quite flat was put down upon it, all
air was expelled from under the latter,
nnd the rim of fluid that formed round
about its margin was so narrow as not
to measure a quarter of the diameter of
the field of the micro.scope even when
the highest magnifying power was used.
In other words, -^^M^ minim was disposed
in a thin uniform layer of the exact size of the cover glass. Hence
the number of bacteria under the glass slip — that is to say, in ^g'o^h
minim— was equal to the number of the bacteria in a field of the
miscroscope multiplied by the number of times the area of that field
went into the area of the covering glass. The micrometer gave the
diameter of the field in thousandths of an inch ; and the cover glass
measured 500 thousandths of an inch across ; and the areas of the
circles were of course proportioned to the squares of those diameters.
All that was needful, therefore, in order to enable me to calculate
the number of bacteria in -^(^th. minim, was to form a fair estimate of
the number of bacteria per field, and this was done by counting the
organisms in a cousidei-able number of fields, and taking the average.
' As the result of the estimate which I made of the number of
bacteria present in every -^th minim, I found it necessary to dilute
the milk with no less than a million parts of boiled water, in order
that eveiy xocj^^i minim should cont:iin on the avei-age a single bac-
terium.'
LACTIC FERMENTATION. 217
Having obtained the necessary dilution Mr. Lister pro-
ceeded as follows : — ' One-hundredth minim of the infected
water was added by means of the syringe to each of five glasses of
pure boiled milk. The result of this inoculation was that only
one of the five glasses was affected at all.' The others remained
unchanged, without fermentation, and without bacteric develop-
ment. The one which was affected underwent lactic fermen-
tation, and in it the bacterium lactis alone was found, no
other form of organism was present. This bacterium was inocu-
lated into urine and developed there. After four days milk was
inoculated from this urine. The milk underwent lactic fer-
mentation, and these bacteria were again found. Drops of urine,
diluted so as to contain three bacteria per drop, caused lactic
fermentation in all the vessels to which they were added.
The following experiments afford absolute proof that the
bacterium was the cause of the fermentation : —
' On August 30 last (1877), having provided sixteen pure
glasses of boiled milk, and having estimated, in the manner
already described, the number of bacteria present in every -^^\\\
minim of a glass of boiled milk, which had been inoculated the
day before by touching it with a heated needle dipped in milk
curdled under the influence of the pure ferment, I diluted a
drop of this milk with boiled water to the requisite degree, and
introduced into each of ten of the sixteen uncontaminatod
glasses a drop calculated to contain on the average a single
bacterium, while five of the rest received each a drop supposed
to contain two of the organisms, and the remaining glass was
inoculated with a quantity in which, according to the estimate,
there would be four bacteria. The result was that within
three and a half days the glass into which four bacteria were
supposed to have been introduced contained a curdled mass,
and tlie five which had received the drops arranged for two
bacteria each had all undergone a similar change. Of the ten
inoculated with drops averaging one bacterium each the
majority were at tliis period still fluid, but some assumed the
solid condition in the course of the next twenty-four hoTU's,
though at different times. P>ut of this series of ten, exactly
five, ns it so hapjwned. remained permanently fluid.'
Every glass in which curdling had occurred contained the
•218 FERMENTATION.
bacterium lactis ; the five glasses in which the milk was
unaifected contained no organisms.
Hence it seems clear that when this organism is present in
milk lactic fermentation occurs. Where it is absent this
change does not take place, for, as jMr. Lister argues, we
could hardly suppose that an organic molecule or ferment
would occur exactly in the same cases as the organisms
appeared, unless there was some intimate relation between
them. If organic molecules, independently of the organisms,
were the cause of this fermentation, some flasks ought to
undergo lactic fermentation without the presence of any
organisms ; others ought to show development of these organ-
isms, but no lactic fermentation.
Other Feo'TJientations, especially the Putrefactive.
I may just refer more as a matter of historical interest than
of real use in this question to Lemaire's experiments with
carbolic acid and his opinions on fermentation.^
Lemaire showed that the addition of carbolic acid to organic
fluids and tissues prevented putrefaction and other fennentations.
Carbolic acid, according to hira, did not interfere with the fermen-
tations caused by ' unformed ' ferments, such as synaptase, &c.
He then pointed out that the unformed ferments can act at
temperatures at which the other ferments are inert, as, for in-
stance, at zero and at 70° C. Trituration of yeast destroys its
fermenting power, w'hile trituration of emulsin does no harm.
In, fact anything that favours life favours alcoholic and
allied fermentations, while anything which is inimical to life is
also inimical to these fermentations, though many of these
things do not interfere with the action of ' unformed ' fer-
ments.
I have before referred to the experiments of Cazeneuve and
Livon on unboiled urine.
The method of obtaining the bladder with its contained
urine has been previously described ; and in the successful
experiments formerly mentioned on p. 37, no organisms were
' L'ac'ulc plii'niqiic, 18(;5.
CAZENEUVE AM) LI VOX. -JIU
found, while if the somewhat concentrated urine were removed
and diluted with ordinary water it became alkaline in twenty-four
hours, and filled with ' torulacee.' Results similar to those men-
tioned were obtained when the urine had been previously
rendered alkaline by the administration of soda or potash.
Puncture of the bladder was soon followed by alkalinity and
development of organisms in the urine : hence it is not the
absence of oxygen from the m-ine which is the cause of the
absence of change in it. The following experiment shows that
the merest trace of oxygen is all that is required, if indeed it
be at all necessary.
Prevent the evaporation through the walls of the bladder,
by immersing it, immediately on its removal from the body, in
melted paraffin at the temperature of 45° C. This temperature
is insufficient to destroy the germs which fell on the wall of the
bladder dming its transit from the abdomen to the paraffin.*
Thus a layer of paraffin covers the outside of the bladder, pre-
venting the rapid evaporation of the fluid which exudes while
living organisms are present on the wall of the bladder. In
twenty-fom' hours remove the paraffin case. It is then found
to contain an alkaline tmbid fluid full of organisms. These
organisms have not, however, had time in twenty-four hours to
penetrate into the interior of the bladder, and therefore the
urine inside is found to be still acid and devoid of life. The
same is the case with ttrine rendered alkaline — the fluid outside
contains organisms, that inside is free.
But let the bladder be first dipped in paraffin at 100° C, so
as to destroy any living organism in contact with the wall, and
then, after removing it from this paraffin at the end of a
minute, let it be plunged into paraffin at 45° C, so as to get a
thicker coat (this paraffin is previously heated to 110° C, and
during cooling is protected from the dust), it will be found that
even after three days the fluid outside the bladder — in the
paraffin cup — is still clear, acid, and devoid of organisms. Leave
this bladder now exposed to the air for say five hours, then
give it a new coating of paraffin at 45° C, and leave this on
' 'I'lie reason why the organisms do not develop on tlie bladder Iiung up in
the air is tliat the fluid dries as soon as it exudes, and therefore tlie organisms
ha\e IKJ tluid in wliirh to develop.
220 FERMENTATION.
for three days. The fluid outside the bladder will be found
in this case to be ammoniacal and to contain organisms.
Hence the walls of the bladder and the fluid in the interior
were not modified by the heated paraffin in the first part of the
experiment.
These experiments alone are sufficient to refute Liebig's view
of organic molecules and decaying matter ; for in the first part of
the experiment they were present in an unlimited amount, but
so long as organisms were excluded no fermentation occurred.
Their bearing also on the theory of spontaneous generation
will be at once evident, and has indeed been already alluded to.
I would only refer here to the experiments in which the urine
was made alkaline.^ and in which therefore we had a natural
alkaline urine full of organic molecules and in contact with the
tissues of the bladder, and yet no organisms appeared in it so
long as the dust of the air was excluded ; in other words, the
alkali had no influence in determining the re-arrangement of
the nur)ierous organic molecules ivhich were -present in the
wcdl of the bladder and in the fluid in its interior^ so as to
form new living beings. This is in exact correspondence with
Dr. Eoberts's results, and is a much more telling experiment.
Some very remarkable and convincing facts have been lately
obtained by Dr. Paul Bert.'
On subjecting the ' unformed ' ferments, such as ptyalin,
pepsin, inversive ferment, myrosin, find eraulsin to high degrees
of pressure, he found that the properties of these ferments were
not in any way impaired.
Thus to quote Experiment 467 : —
' 21 Juillet 1 874. Saliva humaine etendue cl'eau et plac^e clans un
mairas etii^e a la lampe, et soumis k 15 atm. d'un air suroxygdne.
' Le 30 Juillet je decompinme et soude I'extremit^ du tube effiI6.
' 18 Janvier 187.^. Cette saliva qui ne. sent rien et parait bien
noi-male, neutre aux reactifs, transforme avec une grande 6iiergie
I'amidon cnit en glycose.'
It was proved by a former experiment (p. 201) that the amy-
lolytic property of ptyalin was not altered by diminution of
pressure, and the same is true when the pressure is increased:
' La Pi-egsion haromvir'uiuc.
PAUL BERTS EXPERIMENTS. 221
and, what is of great importance, other ferments of the same class,
which axe apt to lose their properties when kept, owing to the
occmrence of putrefaction, retain these after being subjected
to strong pressure if new causes of putrefaction are excluded.
The explanation of this fact is simply that the bacteria and
fungi are killed by the high pressure.
Bert also enquired whether these ferments could continue
to act, in this compressed air, and he found that though they
did continue to act the rapidity of their action was manifestly
diminished. Thus Exp. 470 : —
' 20 Janvier. Salive, amidon cm et eau. Bien mele et place dans
plusieurs tubes. On s'assme que le melange ne contient pas de
glycose.
' A — a la pression normale, bouche avec coiiiet de papier leu verse.
'B — a 21 atm. d'air suroxygene.
' Tous les deux sont mis a I'etuve, 30 degi-es.
' 25 Janvier. Essay e avec liqueur bleiie : —
' A — 7ce en redui&ent 35 gouttes.
' B — 7ce en reduisent 14 gouttes.'
This result was, however, not obtained unless the fluids were
examined within a few days. At a later period, especially if
diastase was employed, the contrary was found ; the fluid,
subjected to compression, containing more sugar than the other.
It was found that the explanation of this was that the diastase
which had remained exposed to the air had become altered,
owing to the growth of organisms in it, while organisms being
unable to develop in that subjected to high pressure, the
diastase had retained its properties and continued to act.
Paul Bert concludes : ' All the soluble false ferments with
which we have experimented, diastase, ptyalin, pepsin, inversive
ferment, myrosin, emulsin, have yielded the same result, and
liave retained their characteristic properties, after the prolonged
action of oxygen, at a high pressure. Indeed, as this compressed
oxygen destroys the germs of fungi, vibriones, &c., which
sooner or later destroy these ferments when exposed to ordinary
air, the latter remain unaltered for an apparently indefinite
period of time.'
If we now coni])iux' these f.icts with lliosc oblained by sub-
jecting the ' true ' ferments — those causing putrefaction, &c. — to
2-2-2 FERMENTA TION.
high pressures, we shall find a remarkable contrast ; the latter
class of ferments behave under high pressures like living beings,
not like the unformed ferments just mentioned.
Bert says : ' The most striking face which has been made out
in these experiments is that, in air sufficiently compressed,
putrefaction does not occur, no disagreeable odour manifests
itself, and muscle, for instance, preserves its normal appearance
except in colour ; its microsco})ic structure is not markedly
altered.'
Thus Ex}). 404. ' 17 Mars. Viande en morceaux et eau ; dans 2
petits matias effilus a la laiiipe. A — a la pression noimale.
' B, B' — a 16 atmospheres d'une compression faite avec de I'air
contenant 80 pour 100 d'oxygene.
' 26 Mars. Decompiime. A, pouni, infect. B n'a pas d'odein- et est
neutre aux papiers reactifs,'
But this is not all ; for when one restores the pressure to
the normal, taking sufficient precautions to prevent the
entrance of new organisms from without, putrefaction no longer
occius, and unboiled meat may be preserved at the normal
pressure for an indefinite time after being subjected to high
atmospheric pressures. The precautions required to prevent
the entrance of organisms after the compression, and to ensure
the complete destruction of those present, are detailed on p. 184.
Exp. 407. ' 20 fevrier. On met dans 1.5 tubes 15 morceaux de
viande pesant chacun 1 gr. Ces tubes sent ensnite etires a la lamj)e et
soumis dans I'appareil en fer, a 15 atmospheres tr6s-siiroxygenes.
' 3 Mars. On decomprime avec precaution et Ton ferme a la lampe
les 15 tubes. L'analyse de 3 d'entrc eux, faite aussitot, donne de 70
a 80 povir 100 d'oxygene.
' 13 Mars. ' On brise nn des tubes sous le mcrcure : viande ambreo,
pas d'odeur, reaction acide. On trouve 6-2 pour 100 d'acide carbo-
nifpie et 77-8 d'oxygene.'
From a large number of experiments Bert finds that a pres-
sure of twenty-one atmospheres is sufficient to kill the organisms
which cause putrefaction. Similar facts were made out as
to fermentations in blood, eggs, urine, milk, alcoholic fermen-
tations, &c. A fact which he observed more especially in con-
nection with blood and milk, is worth mentioning. He found
that in the case of milk, as in the case of other substances.
PAUL BERTS EXPERIMENTS. 223
putrefaction was arrested by compressed air. But if tubes
were used neither coagulation nor rapid acidification were
prevented. Was this because oxygen in tension was without
action on the bacterium lactis ? or was it that the coagulation
of milk was not the work of these microscopic organisms, but
rather of some agent which can resist oxygen, as we have seen
to be the case with the ' unformed ' ferments ? On further in-
vestigation, however, he found that the result depended on the
thickness of the layer of liquid. If it was thin the tendency
to coagulation was destroyed.
Exp. 431. ' 10 Aout. Lait bouilli ; mis £^n couche de 2 a 3
millimetres d'epaisseur dans deux cristallisoirs neufs et bien laves.
' A — a Fair libre, sous un verre qui arrete les poussieres.
* B — a 25 atmospheres d'air suroxygene.
' 14 Aoiit. Decomprime.
' A est coagule depuis le 11 et sent tres-mauvais.
' B est licjuide, ne sent aucune odeur et parait normal.'
Paul Bert sums up his results with milk as follows : ' These
experiments prove in a very conclusive manner that oxygen in
a state of high tension prevents the coagulation of milk, that is
to say, kills the vibrios which cause the lactic fermentation.
As the action of these organisms is very rapid, it is necessarv,
in order to arrest it, to employ oxygen at very high pressures
and to have the fluid in a thin layer, so that the oxygen can
saturate it quickly. In the case of putrefaction, which
occurs much more slowly, these excessive precautions are not
necessary ; milk differing from blood in not consuming the
oxygen as it penetrates the liquid, the gas has time to reach
the bottom of the tubes and to kill all the jjutrefactive agents
present. This fact explains how one can so easily, by means
of compressed air, prevent milk from putrefying, and yet have
so much difficulty in preventing its coagulation.'
It would be superfluous to pursue the })roof of this matter
further. The greater part of the preceding ])ortion of this
work has consisted of evidence which, taken together, can leave
no doubt on the mind that putrefaction, like other fermen-
tations, is caused by the growth of organisms in the putrefying
material Pasteur's researches have Itnl him further, and caused
2-M FERMEXTATIOX.
liini to adopt a theory of fermentation which has certainly
many facts to support it, though I doubt if it can hold good in
many instances. He thinks that when a substance putrefies
two classes of microscopic organisms are at work, the first in
point of time being chiefly engaged in abstracting the free
oxygen from the material, and the second, which then appear,
being unable to live in free oxygen, but nevertheless requiring
oxvgen for their growth, and obtaining it from the chemical
combinations present. The result of this extraction of oxygen
is the breaking up of these compounds — their putrefaction —
and the rearrangement of their elements to form new com-
pounds, which constitute the products of putrefaction. Whe-
ther Pasteur's theory be true or not, all the experimental results
taken together, as well as the numerous facts known as to the
power of antiseptics in arresting this class of fermentations,
render it no longer doubtful that the particles which fall
into organic materials and cause fermentations there, are the
same as those which, falling on the same substances, give rise
to the lower forms of organisms ; in other words, are bacteria
or their spores.
MICRO-ORGANISMS IN THE LIVING BODY. -255
CHAPTER XII.
RELATION OF MICRO-ORGANISMS TO THE FLUIDS AND TISSUES
OF THE LIVING BODY.
Proposed mode of enquir}^ — Does the aseptic method prevent putrefaction ?
Does it exclude organisms from wounds ? Ranke's results : Klebs' objec-
tion : Ranke's reply : Demarquay : Fischer : Schiiller : my own method —
Results in aseptic wounds — Results in wounds treated otherwise — Koch's
method of staining pus — Results in cases not treated aseptically — Exam^Dles
of complete exclusion of organisms in aseptic cases — Examples of the en-
trance of micrococci in aseptic cases — Definition of micrococci — Distinc-
tions between micrococci and bacteria. Are organisms present in the
healthy living body 1 — ' Bistournage.' Are organisms present in the body
in states of disease ? — Experiments with ammonia, phosphorus, &c. — The
healthy blood and tissues can destroy organisms — Relation of organisms to
abscesses. How do micrococci enter aseptic wounds ? Carbolic lotion a
sufficient germicide ; Spra}^, its value — Stimson's experiments ; Gauze dress-
ing as a protection against entrance of organisms ; Carbolic acid as a
germicide in albuminous fluids ; Relations of micrococci and bacteria to
fluids containing carbolic acid. Conclusions.
All the experiments which have been referred to as yet
relate to fluids and tissues removed from the body and pre-
served in flasks. It now remains, before quitting the subject,
to enquire if our conclusions hold good for fluids and tissues
retained in connection with the living body. An investigation
of this sort has been demanded by some writers, as, for instance,
by Mr. Holmes. At least that is what I take him to imply by
the following passage' (I can see no other meaning in it):
'When we are told that, in order to practise antiseptic surgery,
we must believe in the germ theory, then I cannot but say that
belief is not a voluntary act ; it must follow upon proof, and
no convincing proof of the germ theory as applied to living
tissues and living pheno7nena has, as far as I know, yet been
offered.' Granting that I inteqn-et Mr. Holmes' meaning
aright, I venture to differ from him as to the necessity for such
' See MacC'ormac's Antisejjtic Surgery, p. 51.
Q
226 FERMENTATION.
facts, but nevertheless I think it well to introduce here some
investigations which I have carried on with reference to this
question.'
The mode in which I propose to ascertain whether the
former conclusions apply to the living body or not is by the
examination, in various ways and under varying circumstances,
of fluids and tissues in the body.
We have before seen that the method which we have agreed
to term the aseptic method of treatment is nothing more or
less than a series of experiments on the germ theory of putre-
faction— experiments made with the object of rendering atmo-
spheric dust inert before it reaches the wounds. We shall
attain the object of the present enquiry by ascertaining how
far these experiments are successful. In discussing this ques-
tion the following points suggest themselves : —
Does the aseptic method of treatment prevent putrefactive
or other fermentations in the discharges or tissues of wounds ?
If putrefaction is prevented are organisms also excluded ?
If under any circumstances organisms do enter wounds so
treated, what are the peculiarities of these bodies ?
Are organisms present or do fermentations occur in fluids
or tissues in the living body, which have never been exposed
to the atmospheric dust ?
If organisms are present, how is their occurrence to be
explained ?
If organisms enter wounds treated aseptically how do they
get in ?
1. First, then, does this method prevent putrefaction ? Un-
doubtedly it does. Compare the course of an abscess, con-
nected with diseased bone, opened and kept open without
aseptic precautions, with that of one opened in accordance
with strict aseptic principles. In the former case the i)us
raj^idly undergoes fermentation, in all i)robability putrefaction ;
in the latter case the discharge does not undergo fermentation,
and remains sweet and pure till healing is complete, however
long that may be. I have at this present moment in my mind
such a case. A patient, a young woman, came under Mr.
' For many details not luentioued here, see the Transactionis of the
Pathol nijica I Sorirty for 1879.
MICRO-ORGANISM^'^ IN WOUNDS. 227
Lister's care in August 1876, with spinal disease and psoas
abscess. Subsequently a psoas abscess appeared on the other
side, and later a lumbar abscess also. I dressed the case almost
from the first myself, and though these dressings were changed
at first daily and then ultimately weekly for nearly four years
(for complete healing did not occur till June 1880, though
there had been, for a long time, only minute sinuses furnishing
almost no discharge), yet neither putrefaction nor any other
fermentation ever occurred in the discharge from these wounds.
Indeed, I may say, from long experience of Mr. Lister's practice
and from long use of his method myself, that one who has
had some experience in this method may now reckon with
certainty on avoiding putrefaction or other fermentative change
in discharges from any wound made in a situation where
aseptic dressings can be applied, provided always that the
treatment be strictly carried out by the method described at
length at the beginning of this work.
2. Such being the facts with regard to the absence of
putrefaction, is it equally the case that organisms are absent
from the wounds ? We saw a constant relation between the
bacterium lactis and the lactic fermentation : can similar facts
be found with regard to aseptic and septic wounds ?
The first communication on this subject was made by Dr.
Ranke,' of Halle, in 1874. He published a note of 300 exami-
nations of the discharge from fifteen wounds treated aseptically,
and following an aseptic course, in which he states that on only
one occasion did he fail to find organisms. His method was
v^imply to look at the discharge through a microscope, and it
was not a particularly high power which he employed. The
organisms which he says were present were for the most part mi-
crococci in pairs, also streptococci ; more rarely small or middle-
sized bacteria. He did not carry his investigations farther, but
on this evidence he rejects the germ theory as sufficiently
explaining the etiology of septic diseases.
While by some these observations have been regarded as
accurate and as confirming their previously formed views, by
many they have been looked on as erroneous, either from having
been made on cases in which the aseptic method had been
' Chirurg. Centralhlatt, No. lii, 1874.
ti 1.'
228 FERMENT A TIOX.
imperfectly carried out, or in themselves faulty. In answer to
objections of the former nature urged by Professor Klebs ' of
Prague, Dr. Eanke^ published another paper in July 1876,
quoting cases to show that the treatment had been in reality
properly carried out. He instances especially cases of hydro-
cele, treated by making a small incision into the sac with
aseptic precautions and stitching it to the skin, where cure
followed without any inflammation or constitutional disturbance,
but where, nevertheless, organisms were present in the dis-
charge. From those cases, as well as from the various pub-
lished reports of the results of Professor Volkmann's practice,
there seems no reason for doubting that the observations were
made on wounds treated with all due precautions, and following
an aseptic course similar to that which Mr. Lister himself
would expect.
About the same time Demarquay ^ published the results of
eight cases treated ' antiseptically,' in all of which organisms
were found. The general course of the wounds so treated, as
described by the author, and the fact that one of the eight
cases died of pyaemia, show that whether the cases were treated
antiseptically or no, they were not treated aseptically.
Two years later there appeared a paper by Dr. Fischer of Stras-
burg,'* giving the result of investigations carried on in Professor
Llicke's wards. He employed chemical tests, especially acetic
acid and glycerine, as recommended by Von Eecklinghausen,
and he found organisms in all the cases examined. He, how-
ever, states that bacteria were not imfrequently present, his
results differing in this respect from those of Dr. Eanke. Now,
it so happens, I spent the summer of 1876 in Strasbjirg, and
thus had frequent opportunities of seeing the ' aseptic practice '
in that hospital, and 1 can only say that I was not sui-prised
when I heard that bacteria had been found in the wounds.
The last paper on this subject was published by Dr.
Schiiller^ in the spring of 1877. In his investigations at-
' Archivfiir ExperimvtAclle Patholor/ie, Bd. iii. p. 315.
- Deutsche Zeitschrift fUr Ckirurgie, Bd. vii. p. 68.
3 Comjjics-Bendiis, 1874.
' Deutsche Zeitschrift filr (,'hvnirfjic, Bd. vi. p. 320.
* Ihid. Bd. vii.
EXAMINATION OF ASEPTIC WOUNDS. '2->U
tempts were made to cultivate organisms from wounds. He
found that in many eases organisms were absent both from the
discharge and the cultivating liquid, whilst in other cases they
were present. He does not specify what the nature of these
organisms was, and he is inclined to associate their presence in
wounds with the occiurence of tension, &c. There are various
objections to his results, but these I need not stay to discuss.
As long ago as 1876 I began a series of investigations on
this matter. My first observations were of the same nature as
those made by Dr. Fischer; that is to say, I not only examined
the discharges microscopically, but I also treated them with
acetic acid and glycerine. These substances are recommended
by Professor Recklinghausen for this purpose, the glycerine being
supposed to dissolve the fat granules and the acetic acid to
render the protoplasm invisible ; thus, only nuclei and micro-
organisms are left. On treating pus in this way I found that a
large quantity of granular matter remained, and, though I very
soon arrived at the conclusion that bacteria — i.e. rod-shaped
organisms — are not present in the discharge from cases treated
asejjtically, I could not say whether among the granular
matter seen there were or were not micrococci. This difficulty
is the greater as there is more granular matter in aseptic
wounds than in others.
I therefore soon commenced a series of cultivation experi-
ments. The following was the principle on which I acted. On
introducing a particular form of organism into a suitable pabu-
lum with precautions against the entrance of others, this form
of organism will grow there. This being the case, theoreti-
cally one would only require to inoculate some suitable pabulum
with various discharges — on the one hand to get a development
of organisms, on the other to find the fluid remain free from
organisms, and unchanged. Various preliminary experiments,
which I need not detail, established this. For the present
investigation some suitable pabulum must be taken, sterilised,
and inoculated under proper precautions with discharges from
wounds. If we have a really pure pabulum, and the inocula-
tion has been carried out in such a way as to prevent the en-
trance of any extraneous organisms, the inference, where
development occurs, would naturally be that organisms have
280 FERMENT A TIOK
been present in the fluid from which the inoculation was made.
If, on the other hand, the same method has been employed,
and no organisms develop, the inference would be that no
ors^anisms existed in the fluid.
I first used milk, but for various reasons I gave it up, and
tried Pasteur's and Cohn's fluids, and, after reading Schiiller's
paper, Bergmann's ; but I found these artificial solutions too
insensitive to be of any value for my purpose. I then used
vegetable infusions, more especially turnip, and ultimately
infusion of cucumber, which last seems to be very sensitive.
I also employed in many cases an infusion f meat.
The infusion having been prepared, is filtered, introduced
by syphon into Mr. Lister's double-necked flasks, boiled for
twenty minutes, kept for some days (at least two) in an incu-
bator, and then decanted under a spray of carbolic acid into
smaller purified flasks, which are likewise placed in an incubator
for several days before being used. These flasks are covered
with cotton wool caps purified by heat or carbolic acid, or they
stand on a glass plate and are covered by a glass cap and a glass
shade, as described before in the case of Mr. Lister's liqueur
glasses.
For the purpose of inoculation, small capillary tubes, such
as those used for vaccination, were employed. These possess
the advantage over needles, in that, while they take up a larger
quantity of the discharge, they protect it from the carbolic acid
of the spray during the transit from the wound to the flask.
The tubes are dropped into the flask containing the cucumber,
and this is then placed in an incubator kept at the temperature
of the human body. (See Fig. 72.)
The procedure maybe shortly described as follows: — The
outer portion of the dressing having been removed under the
carbolic acid spray, a tube which has been previously purified
in carbolic lotion is heated in the flame of a spirit lamp in the
spray, so as to drive off all the carbolic lotion and to render it
dry. This tube is now rapidly introduced into the drainage
tube, and from thence immediately into the flask which is
opened in the spray close to the wound. The flask is then
placed in an incubator kept constantly at a temperature of
98° Fahr. In the case where flasks with cotton caps are used
EXAMINATION OF WOUNDS.
231
it is well in performing an experiment to wet the margin of the
cap with carbolic lotion before lifting it, so as to prevent any
dust from falling from the cap into the fluid. This is a very
important precaution.
Having ascertained that the method proposed was perfectly
trustworthy, I proceeded to the investigation.
In performing the experiments I always inoculated two
flasks, and often another was taken and the whole process gone
through in the same place, with this difference, that the tube
in the latter case, when heated, was put directly into the flask
without touching the wound. These latter
flasks remained, without exception, clear.
When development occurs in the flasks
inoculated the fluid generally becomes
muddy in 30 to 50 hours, but where the
fluids remained clear I have kept them in
the incubator for weeks, and then tested
them by the addition of some substance
containing bacteria.
As a result, I find that in cases treated
aseptically, where of course there was an
unbroken skin to start with, one of two
things may happen — either the fluid re-
mains perfectly clear, without the develop-
ment of organisms, showing that none were
present in the wound ; or the fluid becomes turbid from the
presence in it of organisms of the form seen in Fig. 1, Plate I.
In both cases the wound may follow an aseptic course ; i.e. no
local or constitutional disturbance results from the operation,
and from the appearance of the wound one could not tell in
many cases whether these organisms were present or absent.
From Fig. 1 it will be seen that these organisms are minute
spherical bodies arranged in pairs ; in t riplets, in which case
they form a triangle (a very important point in distinguishing
them from other forms); in groups of four (positions which
bacteria never take up) ; also in short chains and groups of
larger or smaller size. In fact they belong to the group of the
Bchizomycetes termed micrococci.
I have said that in many cases one could not tell from the
Fig. 72. —Flask con-
taining CULTIVAT-
ING FLUID INOCU-
LATED FROM A
WOUND.
202 FERMENT A TIOX.
course of the wound whether these organisms are present or
absent, but sometimes their presence can be suspected. Those
who have worked long at aseptic surgery will have met with
cases where when a dressing is left on for six or seven days, or
when adeep dressing is left for some weeks, the discharge acquires
a sour odour and the skin around the wound becomes somewhat
excoriated. As the wound in other respects follows an aseptic
course, Mr. Lister concluded that this was probably a chemical
change taking place between the discharge and the materials
in the gauze dressing. Knowing the peculiar property pos-
sessed by salicylic acid of preventing chemical fermentations,
Mr. Lister uses it in such cases with the effect of diminishing
or preventing this change.
In these cases I have always found micrococci.
If micrococci be grown in a small quantity (3 to 8 drachms)
of cucumber fluid, after three days they seem to die ; at any
rate, they will not grow in any liquid. But yet if the fluid be
kept for some weeks it will gradually become red, till it ulti-
mately is of a dark vermilion tint. Thus chemical changes
continue after the activity of the organism has ceased. May
not something of the same kind occur in these cases ? Chemical
changes are primarily set agoing by these organisms, but con-
tinue of themselves, and thus salicylic acid acts by preventing
these changes, as Mr. Lister supposed, though, according to
this view, the organisms are necessary for their commencement.
If now we contrast these results with those obtained in
wounds not treated strictly asej^tically we find this marked
difference, that in none of the latter were organisms absent^
while in almost all bacteria as tvell as micrococci were present.
It is to be observed that in many of the cases antiseptics were
employed, both in the external dressings and injected into the
wound, but no precautions were taken either to penetrate to all
the recesses of the wound with the antiseptic so injected, or to
prevent the access of organisms during and after the dressings.
I may mention that in four cases which were originally
treated aseptically bacteria were found, but in all these their
presence was indicated by disagreeable smell or by symptoms
of local or constitutional disturbance. It is thus evident that
bacteria as well as micrococci can flourish under an antiseptic
KOCH'S METHOD. 233
dressing. The explanation of their absence must therefore
be that the circumstances which permit of the entrance of
micrococci are not such as to allow the advent of bacteria. ■
It was thus satisfactorily established that there was a very
marked difference between the discharges of aseptic wounds
and of those not treated aseptically. From the former,
organisms were generally absent till about the end of the case
when the dressings were left on for several days. In the
latter, organisms are ^present, even within the first twenty-four
hours. Again, in the former, when organisms did appear they
constantly belonged to the group of micrococci, in the latter
rod-shaped organisms were frequently present as well, and
generally in large quantities if there was any putridity in the
wound.
It was just possible that an objection could be brought
against these results to the effect that organisms might have
been present in the discharge of aseptic wounds, but that they
were unable to develop in the fluid used for cultivation. To
obviate this objection as far as possible I used a variety of
cultivating fluids and got the same results with all.-
During the spring and summer of 1880 I renewed the study
of this subject in a different manner. I adopted Koch's
method of staining bacteria ' and I employed it in all Mr.
Lister's cases from the beginning of March till the end of June
(four months), and my results confirm in every respect those
which I had got by the method of cultivation.
I find that, in the first few days after an aseptic operation no
organisms can be found in the discharge, and that, when they
ultimately do appear, they are micrococci, not bacteria. On the
other hand, after operations not performed aseptically organisms
are generally present from the first, and as a rule these consist of
bacteria as well as micrococci.
The principle of this method of staining is that various
aniline dyes, more especially metliyl violet, fuchsin and aniline
brown, stain chiefly the nuclei of cells and bacteria ; though these
are generally the only bodies stained, yet in some cases, especially
if the staining is excessive, other albuminous granular matter
may also become coloured. However, even where such is the case
' See Cohn's Bcitr'dgc znr liiologif dcr PJianzcn.
234- FERMENTATION.
the organisms can, as a rule, be easily recognised by their form
and arrangement. The pus or other fluid to be examined is
spread in a very thin layer on a cover glass or slide, and left to
itself to dry or dried over a spirit lamp. In the case of albu-
minous fluids it is well to do nothing more for at least twenty-
four hours. These cover glasses may be kept for months and
then used, for no organisms can grow on the dried materials.
In order to stain the specimens a few droj^s of a saturated
solution of methyl violet or of fuchsin in alcohol are added to
distilled water till a sufiicient depth of colour is obtained. This
can only be determined by experience, but it is well to stop be-
fore any precipitation can be detected. (Dr. Ogston recom-
mends a watery solution of methyl violet of the strength of
half a grain to the ounce.) A drop of this solution is allowed
to fl-ow over the cover glass, being retained in contact with the
material to be stained for about one minute. It is then washed
off with distilled water and the cover glass again dried as before.
When quite dry it is mounted in Canada balsam.
When aniline brown is used a concentrated solution in
glycerine i^ prepared. This is filtered, and one part of the
filtrate is added to an equal quantity of distilled water and an
equal quantity of pure glycerine. This mixture is now filtered and
is then ready for use. I find that this fluid, while it does excel-
lently for staining organisms in such fluids as cucumber, turnip
infusions, &c., does not stain them well in pus. I find it best
in the latter case to place a drop of the staining fluid on a slide,
then lay on the cover glass, the material to be stained being of
course lowermost. Leave this for twenty-four hours and then suck
out the staining fluid with filter paper, introducing in its stead
pure glj'cerine. This is a difficult process, and the specimens are
frequently not quite clean. However, if one examines the layer
attached to the cover glass, one sees what was in the material ;
the fragments which are floating free may consist of all sorts of
debris. The specimen is then surrounded with cement.
The results of these methods of staining are very beautiful.
If the staining is not too intense, only the nuclei of the pus-cells
and any organisms which are present are stained, and the latter
can be recognised with the greatest readiness with a sufficiently
high power.
RESULTS OF THESE INVESTIGATIONS. 285
So much for the method. Plates I. to IV. illustrate the
results.
Let us take first some specimens from wounds which have
not been treated aseptically. Here it will be seen that there
are always organisms, and that these generally consist both of
bacteria and micrococci, though sometimes of one or other alone.
Look at any wound not treated aseptically, which has not united
by first intention, and which has been somewhat recently made,
and you will get this result.
Case \. — Fig. 2 is a specimen of the discharge taken from a com-
pound dislocation of the thumb a few days after the accident. The
wound had not been treated aseptically, and it had a very foul smell.
(The patient, by the way, died of tetanus.) Here a great variety of
organisms will be found — bacteria, bacilli of various kinds, and
micrococci.
Case 2. — Fig. 3 is a specimen of discharge taken from a wound of
the scrotum in which a small slough was Ipng. The wound was
syringed out daily with carbolic lotion 1-40, and dressed with boracic
ointment. The discharge had a very foul smell. Here there are
multitudes of minute bacteria, bacilli, and mici-ococci.
Case 3. — Fig. 4 was taken from a case in the out-patient room,
not treated aseptically. There was not much discharge and no jiutrid
odour ; rather a slightly rancid smell. Here well-marked liacilli
can be seen. Discharge taken on two occasions presented the same
appearance.
Case 4. — Fig. .5 was taken from a case of amputation of the thigh
which had been done two days previously, and had been treated by
irrigation, though I must say, for the credit of irrigation, not very
efficiently. Here there was a slight smell. Bacilli are present.
Case 5. — Fig. 6 was taken from a case of excision of the hijj-joint
where numerous sinuses existed previous to the operation, and whei-e,
therefore, there was no hope of eradicating putrefiiction. I dressed
this case myself, washing out all the sinuses daily with 1-40 carbolic
acid lotion, and applying boi-acic or salicylic acid ointment, and out-
side this boracic lint. The specimen figured was taken more than
four months after the operation, and contains numerous bactena ;
this, observe, although the wound had been treated assiduously for
months with antiseptics, but not aseptically.
At the end of March some pieces of dead bone were fdt, and
these were removed on April 1st. The wound and sinuses were
thorougldy washed out with chloride of zinc and dressed as before.
230 FERMENT A TION.
The disoharge, taken two days later (on April 3rd), had a putrid odour,
and contained numerous large and small bacteria.
On the following day (April 4th) it presented the same appearance.
Sixteen days after this second operation (on April 17th) there were
still numerous bacteiia present
Case 6. — Take again a case of Syme's amputation performed on
March 9th, 1880, for disease of the ankle-joint. Several sinuses were
included in the flaps. Free drainage was employed, and salicylic or
boracic ointments and boracic lint. This case went on veiy well ; i.e.
there was at first a little odour, but this was very slight and soon
almost entirely disappeared. The discharge got less, and the wound
came to look somewhat like an aseptic wound.
Fig. 7 (March 15th, from drainage tube) shows chiefly streptococci
in pairs ; no typical micrococci, nor the colony form of micrococci ;
small bacteria ; a few long rods.
On March 17th the discharge taken from the drainage tube con-
tained chiefly oval bacteria ; also streptococci {i.e. spherical bodies in
chains) ; no typical micrococci ; a few long bacteria.
On April 12th the organisms were much less numerous, there being
only a few streptococci and bacteria.
April 14th, very few organisms — streptococci.
April 16th, I'ather more organisms than in the last — only strejito-
cocci. There had been a little retention of the discharge.
May 14th, a considerable number of streptococci; also a few oval
bacteria : drainage not quite perfect.
Here we see that organisms were present, but so long as the
discharge flowed freely away, they did not develop. When tension
occurred they grew. The wound did very well, and forms of micro-
cocci were the chief organisms present.
So much for examples of cases not treated aseptically. In
all cases organisms were present, and these were almost always
bacteria. The more putrid the discharge, the more numerous
and the smaller were the bacteria (Bacterium termo?). The
better the progress of the wound, and the better the drainage,
the fewer the organisms ; but nevertheless there was always
some form of organism present, and had I inoculated infusions
from them, I should certainly, according to my former extensive
experience, have got bacteria, as well as micrococci, to develop
in all cases. The significance of the diminution in number of
the bacteria in the last case is a point which I shall not discuss
here. I will merely state that in some wounds following a
RESVLTS IN ASEPTIC WOUXDS. 237
very satisfactory course micrococci only can be found by this
method of examination.^
Let us now look at cases treated aseptically. I shall only
mention a few instances, but I may state that I have examined,
in almost all cases, specimens of discharge taken at every dress-
ing with the same results as are illustrated here.
In the first place, I will give two cases which show that all
forms of organisms may be permanently excluded by strict asep-
tic treatment.
Case 7. — Take first the most testing case of all — one of em-
pyema. Here at each change of the dressings air is sucked in with
every inspiration, but when the dressing is done with aseptic pre-
cautions, this air has been acted on by carbolic acid. We shall
therefore see whether the spray is efficient in destroying organisms.
The case of empyema to which I refer was one of considerable
standing, and was opened aseptically on March 7, 1880. The cavity of
pleura was not washed out, and during the whole of the treatment no
carbolic acid or other antiseptic was applied to the interior. Hence
if organisms got in, they could develop just as freely as in a flask.
There were no organisms in the pus when evacuated. The dressing
was changed daily.
Fig. 8 is a specimen taken on March 15th, eight days after the thorax
was opened. This contains no organisms of any kind, neither bacteria
nor micrococci. Hence for eight days the spray had been efficient.
Fig. 9 was taken on April 13th, i.e. thirty-seven days after the
incision. Specimens examined in the interval were free from or-
ganisms, and here it will be seen that there are no organisms of any
kind. This result is the more convincing, as for some days there had
been a difficulty to the exit of the fluid, and some discharge was pent
up in the lower part of the thorax. This was let out on April 13, and
the specimen was taken from this fluid. Now my invariable experience
has been, that when such accumulation occurs, if organisms were
present before, they will be found in large numbers in the retained
fluid ; in fact they develop just as freely as if the fluid were in a flask.
A specimen taken on April 19th — i.e. forty- three days after the in-
cision— was also free from organisms.
This case seems to me an absolute proof of the efficacy of
' In these cases, Ihou.^h iiiicrncocci alone could he found, yet cultivation ex-
periments would in all ))robal)ility have revealed the ijrosence oi' bacteria as
well.
l>38 FERMENTATloy.
the spray in destroying the activity of the particles in the air
which give rise to organisms and fermentations ; for here the
action of the living tissues, to be afterwards discussed, could
not come into play — the fluid was under the same conditions as
if it had been in a flask placed in an incubator. The conditions
exactly correspond with my spray experiments (p. 26 et seq.).
Case 8. — Take next a case of incision into the knee-joint in a
case of gelatinous degeneration of the synovitil membrane before
suppuration had occurred. Mr. Lister has found that, in tliese cases,
free incisions on each side of the patella, and the insertion of a
drainage tube into the joint, olten brings about a cure without sup-
duration and without the necessity for further operation. It was so in
this instance. The incision into the knee was made, and drainage
tubes inserted, on May 10th.
On May 14th 7io onjanisms were present in discharge taken from
the drainage tube.
On May 16th, same result. Fig. 10 is a specimen taken on May
20th from the drainage tube : no organisms.
A specimen was also taken on May 20th from a plug of lymph
in a small chronic abscess beside the knee, opened on May 12th, and
here also there were no oiganisms.
On May 22nd there were still no organisms.
I might mention a number of cases to show that where the
dressing is frequently changed, organisms may remain absent
for a long time, or even altogether. Therefore where the
dressing is changed frequently, and where the various aseptic
precautions are thoroughly carried out, organisms never develop
in the discharges.
As a rule, however, the dressing is not changed so fre-
quently, and then, though organisms are absent at the com-
mencement of the case, they frequently appear towards its
termination. In that case, however, the organisms which
appear belong to the group of micrococci.
The following cases illustrate this.
Case 9. — I will t;»ke first a case treated strictly aseptically, and
following a typical ' aseptic course.' This case illustiates the entrance
of micrococci after some days.
The patient, a young man fet. 26, had suffered for a long time
from a sore on his leg, which had now become epitheliomatous. The
MICROCOCCI IX WOUXIJS. 239
patient was very weak. Amputation was performed through the
middle of the thigh. The case followed a typical course. There was
no rise of temperature. The patient felt at once relieved by the
removal of the disease, and his appetite and strength began to improve
from the day of the operation. The wound healed by first intention,
except where the drainage tube was. When this was removed the
sinus became filled with lymph, and this becoming vascularised,
healing took place completely without the occurrence of granulation.
The amputation was performed on April 8th.
Fig. 11 was taken on April 9th (first dressing) from the drainage
tube. Xo organisms, but there is a good deal of granular matter.
Fig. 12, taken on April 10th from the drainage tube (second
dressing). No organisms. Less granular matter. Much less dis-
charge. The dressing was now left unchanged for two days.
Fig. 1 3, taken on April 1 2th from the drainage tube. Xo organisms.
The dressing was again changed on April 14th, and one or two bodies
were then seen which might be micrococci, but of this I could not be
certain.
Fig. 14, taken April 16th. A piece of lymph was clipped away
and rubbed over the surface of a cover glass. There was almost no
discharge. Line of incision soundly healed. The piece of lymph filled
up the place where the drainage tube was. (The drainage tube was
removed on April 14th.) Distinct micrococci; no bacteria; almost
no leucocytes — those that are present being badly formed. The
dressing was now left on for three days, and in a specimen taken on
April 19th from the little bit of lymph there was nothing hut micro-
cocci. No bacteria and no leucocytes. The dressing was now left on
for four days.
In another specimen taken on April 23rd, also from the lymph,
which had by this time become in the main vascularised, micrococci
were present in gi-eat numbers. No bacteria.
Here we see the typical result in a case where the ordinary
rule was followed of not changing the dressing till the dis-
charge comes to its edge. In this case displacement of the
dressing was the cause of the frequent changing of the dressing
latterly. For six or eight days no organisms appeared in tlie
discharge. When they did appear they were micrococci.
Bacteria never got in. Further, the micrococci, though lat-
terly present in enormous numbers, never caused suppuration
nor did they apparently interfere with the healing of the
wound.
240 FERMENTATION.
Case 10. — Case of excision of the mamma and axillary glands for
sciirhus, done on March 19th.
Fi". 15, taken from the drainage tube on March 20th, contained
no organisms.
A specimen taken from the drainage tube on March 21st contained
no organisms.
A specimen taken from the drainage tube on March 22nd contained
one or two micrococci.
These micrococci were more numerous at the next diessing on
March 26th, and they were present in large numbers on March 31st
and on April 2nd ; no bacteria having appeared, as will be seen in the
next specimen.
Fig. ,16, taken on April 4th, when the wound was almost completely
healed. Here there were numeroics micrococci, but no bacteria.
In this case the micrococci got in earlier than we have yet
seen — viz. on the third day after after the operation — but never-
theless bacteria never appeared, and the wound did not seem
any the worse for the presence of the micrococci.
That micrococci may get in even earlier than this, if there
is but little overlapping and much discharge, is evident from a
case of removal of a small epithelioma from the cheek, where
only a small dressing was applied, which was left on for two
days. The discharge obtained on the second day — i.e. at the
first dressing — was found to be full of micrococci. The edges of
the wound were not brought together, but it became filled with
blood-clot, and healing occurred under this without any sui:>pur-
ation at all, and more rapidly than I have ever known it take
place in such a wound, and yet numerous micrococci were
present even from the first.
Case l\ also illustrates this. A keloid was removed from the
back of a man's neck on March 24th. A small dressing was applied,
but there was a good deal of discharge, which reached the edge of the
dressing a few hours after the operation. Specimen 17, taken at the
first dressing on March 25th, shows a few micrococci.
A specimen taken on March 28th (third dressing), and one taken
on March 31st, showed the presence of micrococci in large numbers,
but no bacteria appeared at any time.
And now I come to two cases illustrating very important
points as to the som'ce of these organisms. In these cases I
MICROCOCCI IN WOUNDS TREATED ASEPTICALLY. 241
have examined the discharge, not merely in the drainage tube,
but at some distance from the wound, under the gauze dressing,
and I have found that, though there might be no organisms in
the wound, yet they might be present at the edge of the
dressing, and that micrococci had generally advanced nearer to
the wound than bacteria.
Case 12. — Excision of the mamma and axillaiy glands, done on
March 27th.
A specimen taken on March 28th from the drainage tube (first
dressing) contained no organisms.
Discharge was taken oh March 31st (third dressing) from the
dressing, at a considerable distance from the 'iround. The dressing
had not been changed for two days, and the discharge had readied
the edge some hours before the visit. This specimen contained both
micrococci and bacteria.
A specimen of the discharge taken at the same time from the
drainage tube contained 7io organisms. (See Fig. 18, Plate III.)
Examined again on April 2nd (from drainage tube, fourth dressing).
No organisms found.
Discharge taken on April 4th from the dressing, at some distance
from the wound, contains bacteria and micrococci. (See Fig. 19,
Plate Iir.)
Fig. 20 is from a specimen of the discharge taken at the same
time from the drainage tube, and contains no organisms.
A specimen taken from the sinus on April 6th contained no
organisms.
A specimen taken from the sinus on April 8th contained a few
micrococci. Wound ahnost healed,
A specimen taken at the next dressing from a piece of lymph over
the orifice of the sinus showed numeroiis micrococci.
Here we see that on March 31st organisms had penetrated
for a little distance under the dressing, but had not yet reached
the wound.
The same was foimd on April 4th ; but on April 8th a few
micrococci had got in, and having once got in they multiplied
rapidly. Bacteria did not (jet in. There was no change in
the appearance of the wound to show that anything hurtful had
entered.
Case 13. — This was a case of disease of the knee-joint treated like
Case 7, but hei-e there was necrosis of the patella before operating,
and extensive disease of tlio >)ones. As no improvement followed the
R
242 FERMENTATION.
incisions, excision was performed on April Snd. The drainage tube on
the inner side passed in between the bones, and one was also introduced
into a hole gouged in the bone ; that on the outer side passed into an
abscess cavity in the soft parts. The case followed the typical course.
A specimen was taken on April 2nd from some curdy material
found in the interior of the joint. (It must be remembered that the
interior of the joint had been in communication with the outer world
for some weeks by means of a drainage tube, but there had never
been any suppuration in the cavity of the joint.) No organisms were
found,
A specimen taken on April 3rd from the drainage tuhe on the
inner side contained no organisms.
Fig. 21, taken on April 4th from the gauze at some distance from
the wound on the inner side. One or two micrococci ; no bacteria.
Fig. 22, taken on April 5th from the inner drainage tuhe, con-
tained no organisms. Contrast this with Fig. 21, taken from the
gauze on the previous day. In it there were a few micrococci at some
distance from the wound, but, as we see from Fig. 22, they did not
get in.
Fig. 23, taken on April 8th from the inner drainage tube con-
tained a, few micrococci. They had now reached the inner wound, and
in later specimens they were found in large numbers.
Fig. 24 is a drawing of a specimen taken on April 15th from the
outer drainage tube leading into the abscess cavity. This contained
710 organisms, although they were present on the inner side of the
knee on this same day in large numbers. This shows that the organ-
isms could not have come through the blood or developed spon-
taneously in the wound ; otherwise they ought to have been found
in the outer side as well as in the inner.
From these results — and these are only a sample of what I
have got by this method of investigation — and from my former
cultivation results (each method very important in its own
way), the difference which I have been led to establish between
wounds treated aseptically and those not so treated will be
evident.
Woundi^ treated aseptically are either free from organisras
or, if the latter are present, they are only micrococci. The
others ahvays contain organisons, and, in the great majority
of cases, these organisms are bacteria as ivell as m,icrococci.
III. If, under any circumstances, organisms do enter wounds
treated aseptically, what are their peculiarities ?
PECULIARITIES OF MICROCOCCI. 243
The facts just stated under the second heading imply that
we have to deal in wounds with two great groups of organisms —
rod-shaped organisms, or bacteria ; and spherical organisms, or
micrococci.
Some, however, assert that there is no specific difference
between micrococci and bacteria ; and these observers would
say that the micrococci found in aseptic wounds are simply
bacteria altered in form by the new conditions in which they
are placed. Prof. Billroth, indeed, has gone so far as to assert
that there is only one species, coccos, in the group of Schizo-
mycetes ; that this may under varying circumstances assume the
form of bacterium or coccos, these two being transmutable into
each other. That micrococcus is an organism distinct from
bacterium, is denied by Hallier and doubted by Klebs, while it
is strongly affirmed by Cohn, Eindfleisch and others.
I am now thoroughly satisfied that micrococci are really a
class of organisms quite distinct from bacteria. I have observed
them and worked with them for four years, and I have never
yet met with an instance in which a micrococcus has become a
bacterium, or vice versa.
Before considering the evidence on this point, I may define
what I mean by micrococci. They are (following Cohn)
colourless or coloured round cells, very small, generally under
one micro^millimetre in size, with or without movement, grow-
ing in pairs, triplets arranged in triangular form, short chains or
groups of smaller or larger size, not derived from bacteria nor
developing into them. Other living sphericalbodies maybe found
in cultivating fluids, such as spores of fungi or, indeed, of some
forms of bacteria, as pointed out by Koch ' and Ewart ^ ; these,
however, when fresh nutriment is added, develop again into
fungi on tlie one liand, and into bacteria on the other. The
life history of micrococcus seems only to consist in development
from pairs to short chains or groups of larger or smaller size,
this cycle being repeated on the addition of fresh ])ahulum.
1 need not here enter into the general characteristics of
these organisms, but I may mention some facts which tend to
shew that they are distinct from bacteria.
' Beitr'dffe zur Binlo<jie der Pflnnzen, Bd. ii., 1876.
^ Microscojdcal Journal, vol. xviii.
K 1
244 FERMENTATION.
Tiegel ' has pointed out, that if a fluid containing organisms
be made strongly alkaline with carbonate of soda, bacteria
quickly disappear and only a few micrococci remain, which also
ultimately vanish. This indicates a chemical difference between
the two forms.
A similar chemical difference has been incidentally referred
to by Koch ^ viz., that while 7)xicrococci are stained by haema-
toxylin, bacteria are not.
I have found that micrococci, when acted on by a strongly
peptic solution at the temperature of the human body, remain
unaffected, in contrast to ordinary albuminous granular matter,
which, as a rule, soon disappears. Many forms of bacteria^
similarly treated, become aggregated into clumps, or may for
the most part disappear, only a few irregular rods and granules
remaining. Here again a chemical difference is evident between
the two groups of organisms.
Then as to their mode of growth. I have mentioned the
triangular arrangement of micrococci, and said that this is
typical of these organisms. This is supposed by Cohn to be due
to a looseness of the intercellular substance, allowing the cells
to become displaced. But then this an-angement is constant,
and Mr. Lister^ has by direct observation made out that it is
due to longitudinal division of the cells (Fig. 25). This is a
method of division which never occurs in bacteria. Here again,
then, in their mode of growth we have a marked difference
between the two.
^Micrococci prefer acid fluids ; most bacteria prefer alkaline
or neutral fluids.
Micrococci grow readily, as we shall presently see, in fluids
containing proportions of carbolic acid in which bacteria only
grow with difficulty.
Then, lastly, direct observation has failed to show any trans-
formation of one into the other. I have specimens of micro-
cocci which have remained in cucumber infusion for ten months,
and they were just as perfect micrococci at the end of the time
as at the beginning. There was no transformation into bacteria.
' Virchow's Arcliir. Bd. Ix.
- Traumatic infective diseases.
' 'Tranxactiiins of flic Iloiial Socictij of Edinhnrf/h, vol. xxvii, 1875.
PECULIARITIES OF MICROCOCCI 245
I figure three specimens to illustrate the same point, and in
the note on the next page I give a table of the series of experi-
ments.
The micrococci were obtained from a case of acute abscess
in the groin. When this abscess was opened some of the pus
was introduced into flasks containing meat and cucumber infu-
sions, but nothing developed. On the third day after it was
opened, the dressing having been left on for two days, another
flask of meat infusion was inoculated, and in this micrococci
developed. From this flask were obtained the micrococci in
the series of experiments tabulated below. They were culti-
vated for several weeks in a variety of fluids, but always remained
micrococci of the same kind and with the same effects on the
various fluids.
Fig. 26 represents the discharge from the wound from
which the micrococci were obtained, and is seen to contain
micrococci alone.
Fig. 27 is a drawing of a specimen taken from a flask of
vitreous humour, the third in the series, and here we find only
micrococci.
Fig 28 is taken quite at the end of the series (from c 1 7,
see note), after the organisms have grown in a variety of fluids
(eighteen in all), and yet here we have only micrococci, and
these are similar in appearance to the others. There was here
no development of micrococci into anything else. (I may just
call attention in passing to the proof of the efficiency of the
method of experimentation afforded by these results, and also
to the numerous arguments which can be drawn from them in
favour of the views I am advocating.)
Such are some of the facts which seem to me to show
that micrococci are distinct from bacteria, and they are a
sufficient answer to the question as to whether there is any-
thing special about the organisms found in wounds treated
aseptically.
It is only one well-defined class of organisms which enter
wounds treated aseptically, ivhile in other wounds all forms
may he found.
I will i.ot here enter on the question of the effects of these
micrococci nor will I stop to enquire why it is that no bad
246
FERMENT A TION.
May 8th, abscess in groin, dresscj after two days, contains micrococci
I
Flask of meat, A, inoculated on May 3rd.
I May 6th
m2(:i)
I May 8tli
I
am 1 ^noth^ng)
vl (M)
Mnvintl
m 3 (M)
el
(nothing)
c 2 (M)
I Mnv 1 2th
I I I
e 2 c 4 (II) m 4 (M)
(nothijig) I
I May 14th
m5 (M)
I May 15th
in 6 (M)"
Mavl7th
e3
(nothing)
i I
c 5 (M) e 4
I (nothing)
1 May 19th
c e (M)
I May 2l3t
c7 (M)
I May 24th
c 8 (M)
e5 (M)
Cucumber (M)
eG
(nothing)
I
clO(M)
I May 3l3t
c 11 (M)
c 9 (M)
^fav 28th
a c 1 (M)
I
hy 1 (afewM)
I I
(nothing) c 12 (M)
I June 3rd
c 13 (M)
I June 5th
m 7 (M)
I June 7th
c 17 (M)
Lost from having allowed four days to elapse liefore inoculating again.
In this list m = meat "1 • r •
J. infusion.
„ c = cucumber J
„ V = vitreous humour of sheep.
„ e = fresh egg.
„ am = alkalised meat infusion.
„ hy = hydrocele fluid (very concentrated),
„ M = micrococci present.
LOCAL ACTION OF MICROCOCCI. i47
effects result from their presence. I shall content myself just
now with the following remarks.
It is certain that they do not cause putrefaction, but they
always cause a sort of sour, sweaty smell in fluids — a smell which
can be recognised in whatever fluid they grow : in other words,
they are associated with a peculiar fermentation. Now, the
products of this fermentation are but little irritating. They
have no acrid taste, nor do they feel pungent when applied to a
cut surface. Hence, probably, it is that we find that wounds in
which these organisms exist, even in large numbers, appear
often unaffected by their presence.
Nevertheless, they can hardly, under any circumstances, be
indifferent, and I think I have observed that, in some cases,
after they have got in, the wounds do not behave quite so
typically as usual; i.e. there may be a trace of suppuration, or a
sinus takes longer to heal than one had any reason to expect.
Again, if they get into a wound containing a piece of dead bone —
say, not yet loose — they will grow in its canals, produce their
sour products, and irritate the parts in the vicinity ; and thus
the bone, though not mechanically irritating, because not loose,
nor yet chemically irritating if it is quite aseptic, does become
somewhat irritating and loses its character of an innocuous dead
piece which may be slowly removed by absorption by the neigh-
bouring tissues, and becomes a foreign body which must be
thrown off. In such cases,- then, it would be of great importance
to exclude these micrococci if possible.
An instance which,! believe, illustrates this, occurred recently
in Mr. Lister's practice. We know that formerly, when hempen
ligatures were used, they always came away. If, however, they
are applied aseptically, they remain without causing suppura-
tion, as has been shown in JNir. Lister's cases. The wound heals
over them, and they may indeed ultimately disappear. But
here, as in the case of the dead bone, a necessary condition for
obtaining this result is, that the ligatures be perfectly unirri-
tating. In the case I refer to, Mr. Lister excised the thyroid
gland aseptically, having previously ligatm-ed the vessels, some-
what after Watson's method, with strong hempen twine. The
wound healed entirely by first intention, except where the drain
was, and this also had almost healed by the tenth day. For
248 FERMENTATION.
some days previously, however, the dressing had been left
unchanged, and about the tenth day the discharge, though still
remaining in the main serous, increased in amount. This state
of matters continued till one by one the ligatures came away.
The ligatm-es, when examined, were found to have a distinctly
sourish *• micrococcal ' smell and an acid reaction, and under the
microscope their interstices were seen to be filled with micrococci.
Here we have a perfectly aseptic course for the first few days
till the time came when the dressings were left unchanged for
several days — till, in fact, as we have seen, micrococci got in.
When these organisms appeared they grew in the interstices of
the thread, produced their acrid products, and the thread was no
longer a substance which might become encapsuled or even dis-
appear by^absoi'ption, but it became an irritating foreign body,
which had to be thrown off before healing could occur.
In the same manner, if micrococci entered a healthy joint
where we have a cavity containing nutritious fluid, rather
in the conditions of fluid in a flask than in a cavity in the
living body, I would hardly regard their presence with satis-
faction ; for I should fear that their products would not be
altogether neutral to the sensitive synovial membrane, and
might, at the very least, cause increased secretion and delay
in healing.
These facts are of themselves sufficient to indicate the
advisability of taking all possible precautions to exclude these
organisms. Dr. Ogston has recently assigned much more
serious consequences to them, but the subject is at present too
debateable to be suitable for discussion here.
IV. Are organisms present or do fermentations occm' in fluids
or tissues in the living body which have never been exposed to
atmospheric dust ? If they do so occm*, how is their presence
to be explained ?
This question especially deals with the occurrence or not of
organisms in the healthy living body. I need not enter at
length into this question again ; I have twice already touched
on the subject. I have described the experiments by which it
has been shown that the blood, urine, and milk of healthy
living animals contain no organisms, and possess no inherent
tendency to undergo fermentative changes. Then I narrated,
BISTO URN A GE. 249
both at p. 45 and at p, 196, my experiments on the tissues of
healthy living animals. I need not dilate further on this ques-
tion, but the conclusions to which we were forced were, that the
blood and tissues of healthy living animals do not contain
organisms or their spores, and have no inherent tendency to
undergo fermentation. But it may be objected that these
organs were removed from the living body and placed in flasks,
and that the conditions were not the same as if these tissues
had been retained in relation with the living body. Such an
objection is of no value, because any difference in the condi-
tions is in favour of organisms in the flask experiments, for
the walls of the flask are neutral to their development,
while healthy living tissues are powerful destroyers of bacteria.
This we shall see presently. In the meantime, I will now
bring forward a piece of evidence which completely sets any
such objection at rest. I refer to what is known as the ' ex-
perience du bistournage.' '
This ' bistournage ' consists in rupturing the spermatic cord
subcutaneously by torsion. The testicle is thus separated from
its nutritious vessels, and lies loose in its tunics which protect
it from the access of the air. It adheres to the tunica vagi-
nalis, but the new circulation is insufficient ; the testicle
atrophies and disappears. There are no accidents, because, as
we have previously shown and shall immediately see, the air
with its dust — i.e. bacteria — does not get access to the dead
part.
M. Chauveau who is the author of these experiments, and
whose name is sufficient guarantee for their scientific accuracy,
proved this in the following way : — If the harmlessness of the
o))eration depends on the absence of the putrefactive organisms
which would be carried to the testicle by the air, then these
accidents ought to occur when the germs are carried to it by
the blood. Chauveau accordingly injected organisms into the
vascular system of rams. After the fever, sometimes fatal,
caused by this injection had subsided, he performed the opera-
tion of ' bistournage.' Putrefaction of the testicle occurred in
those animals which had been injected with bacterial liquid.
' See Jeannel's book. Be VInfcction Pirnilc/ity, from whicli the facts are
taken.
L^W FERMENTATION.
Several objections could be urged against the experiments,
and are answered by Chauveau : — '
' 1. Nothing proves that the bacteria in the fluid injected
were the active agents. But the experiment repeated after
careful filtration of the fluid by special filters — i.e. after removal
of bacteria or their germs, remained without effect.
' 2. Nothing proves that it was not the infective fever itself
which caused the putrefaction of the organ. But of two rams
injected with the same fluid and the same dose, putrefaction
only occurred in the case where ' bistom-nage ' had been practised.
Still fm'ther, if in the same animal ' bistom'nage ' is practised on
the left testicle before injection, and on the right after injection,
the right testicle is the only one which putrefies : a proof,
evident and very ingenious, that it is indeed the penetration of
the putrefactive germs into the organ which determines putre-
faction; since the testicle which was separated from the general
circulation before the injection remained indifferent, and did
not undergo putrefaction, in spite of the infection of the whole
body.'
I have also referred to several similar well-known facts at
p. 50 et seq., and Dr. Ogston has tested such fluids as extravasa-
tions of blood, haematoma, contents of pathological cysts, the
fluids of the natural cavities of the body, &c., by means of
Koch's method of staining, and he has failed to find any
organisms. I have also referred to Meissner's recent facts.
From all these considerations we may, I think, conclude that
organisms are not present in the fluids or tissues of the healthy
living body.
Are organisms present in the body in states of disease ? (I
leave out of account here the infective diseases.) If so, how is
their presence to be explained ?
If we investigate animals suffering from disease, we shall
find that in certain cases organisms are present. What these
exact conditions are I am not yet able to say, but I will indicate
some of the cases.
I have found that if an acute inflammatory process be in-
duced in an animal — say by the injection of ammonia — sub-
cutaneously, as pointed out some years ago by Dr. Burdon-
' Quoted from Jeannel.
ORGANISMS IN ACUTE INFLAMMATIONS. 251
Sanderson, the organs examined b}^ the method I have described
may be found to contain organisms.
I have in three instances produced ab^^cesses in rabbits by
the injection of croton oil, and in one case I have found that
the pus of the abscess contained micrococci and bacteria, though
none were introduced at the time. In one of the others I
found only a very few bacilli and in the third I found no
organisms. I shall detail the experiments.
Experiment 1, March 24th, 1881. — Pure croton oil was
introduced into a tube. This was then sealed at both ends,
placed in a sand bath, which was raised to a high temperature
(about 270° F.), and maintained at that temperature for about 2
hours. When it had cooled, one end of the tube was carefully
opened in a spray of carbolic acid, and a pure syringe being
rapidly introduced, some of the oil was sucked up, and at once,
in the same spray, half a minim was injected into the dorsal
muscles of a mouse. The skin of the mouse was very carefully
purified beforehand, and care was taken not to allow any of the
oil to escape along the needle track either in introducing or
withdrawing the needle. The puncture was dried with a
carbolised rag and then touched with collodion.
A flask of meat infusion was inoculated from the oil at the
same time.
On JNIarch 25th (26 hours later) the animal was found
dying, and was at once killed. Great care was taken, in remov-
ing the skin from the back, to avoid contamination of the
deeper parts. The muscles at the seat of injection were found
to be infiltrated with pus, but no trace of the needle track
through the skin could be seen. On examining this pus after
straining, it was found to contain large numbers of organisms,
chiefly micrococci, but a few bacteria and bacilli could be seen.
The meat infusion remained permanently pure.
Experiment 2, April 12th, 1881. — A mixture of equal parts
of croton oil and olive oil was purified and 3 minims injected
into the dorsal muscles of a large rabbit with the same pre-
cautions as in Experiment 1. A flask of meat infusion was
inoculated with this mixture at the same time but nothing
developed in it.
On April 18th the animal was observed to be ill, and it was
2o2 FERMENTATION.
therefore killed. A considerable quantity of pus was found at
the seat of injection. On examination of this pus I found
numerous pus cells, but I have not been able to satisfy myself
that there are any micrococci. A very few bacilli were pre-
sent.
Ex'periinent 3, April 20th, 1881. — 2 minims of the croton
oil mixture used in Experiment 2 were injected into the dorsal
muscles of a large rabbit, with the usual precautions.
On April 25th, though the animal was perfectly well, I
killed it. On examining the seat of injection I found one or two
very small cheesy spots (small abscesses). These consisted of
pus cells and granular matter, but I have not been able to detect
organisms of any kind.
In each of the experiments the pus was stained with
methyl violet, according to Koch's plan, and examined with
Zeis's j:8th oil or ^th water immersion objectives.
Again, I find that if the nutrition of an animal be pro-
foundly interfered with, as in slow poisoning by phosphorus,
organisms may after some time be found in the blood and
tissues. Here, it may be said, inflammation of the intestinal
tract has been caused, and the epithelial barrier against the
entrance of organisms has been removed. But the blood and
tissues, ivheii in a healthy state, have the jpower of themselves
of destroying organisms when these are introduced into the
body. Thus, if into the veins of four medium-sized rabbits I
introduce ^, \, |, and 1 c.cm. respectively, of fluid containing
bacteria, keep the animals alive for at least twenty-four hours,
then kill them and preserve their organs in the manner described,
I shall probably find no organisms in the first three, while in the
last they may or may not be present. Where larger quantities
of the fluid have been introduced, they will certainly be found.
Thus, even though the organisms could gain access to the
blood, yet so long as the nutrition of the animal is fairly well
carried out, they would be destroyed.^ The reason that they
are found where large quantities of bacterial fluid are injected
seems to me to be that, along with the bacteria, their products
' Similar facts have been made out by Traube and Gscheidlen. See a
paper by these authors, ' Ueber Filulniss und den Widcrstand der lebenden
Organismen gegen dieselbe,' Berlin. Klin. Wochcnschrift, No. 37.
MICRO-ORGANISMS IN ABSCESSES. 253
are introduced, that these act in the same way as phosphorus, as
poisons, and that thus the resisting power of the animal is
diminished.
The conclusion which I would draw from these facts is, that
in severe inflammatory processes, or in great interference with
the nutrition of an animal, organisms may pass into the blood
without losing their vitality. The organisms usually found are
micrococci.
I have examined a large number of abscesses, in man, when
opened. At first I only used cultivating experiments, and
this paragraph gives the result of these. In chronic abscesses
I have not as yet found any organisms, and in this my results
agree with those obtained by Billroth by microscopical examina-
tion alone. Of acute abscesses I had up till May 1879 inocu-
lated from thirty-two cases. In twenty-five of these no growth
of organisms occurred, while from six micrococci were obtained.
In no case did I get bacteria (I omit here one abscess in the
ischiorectal fossa, where I found both bacteria and micrococci ;
and one with faecal odour in the lumbar region, from which I
did not inoculate when opened, but in which undoubted
bacteria were seen on microscopical examination).
Professor Billroth has paid special attention to this subject,
and he has found organisms in a larger proportion of acute
abscesses than I have done. Professor Billroth likewise only
mentions the occurrence of micrococci. In acute osteomyelitis,
Avhere a communication had not yet been established with the
external ah', organisms have been found in the medullary canal
or in the pus surrounding the bone by Von Recklinghausen,'
Klebs,^ Eberth,^ and Godlee.'* These organisms were as a rule
micrococci ; bacteria have but very rarely been present.
In 1880 Dr. Ogston,-^ of Aberdeen, published an elaborate
and careful research on the relation of micrococci to abscesses.
In examining pus and discharges for organisms he made use of
Koch's method, before described. In the first place, he found
as I had done, that micrococci were not present in clironic
' iJnttsche Zeitschrift, Bd. iv. p. L':>;i.
' rffiber Si'hii.<tx)ninde/i, 1871.
' Virchow's ArcJiir, V>d. Ixvi p. .Stl.
* Lancet, November 2], 187-1.
* I'lililislied in Lanpenheck's Archir, I'.d. xxv. llefl ,'5.
2b-L FERMENT A TIOX.
abscesses. In acute abscesses, however, he states that these
organisms are always present. This fact, obtained by staining
the pus, differs, as will be seen, from my cultivation results, and
agrees more with Billroth's results from simple microscopical
examination.
Since this statement was made I have examined a number
of abscesses by staining the pus obtained when they were
opened, and T now quite agree with Dr. Ogston. Organisms
are always absent from chronic abscesses. Micrococci are
always present in acute abscesses.
Fig. 29 (Plate IV.) is a specimen taken from a chronic
abscess over the sternum. It contains no organisms.
Figs. 30 and 31 are taken from acute abscesses — one of the
mamma, and the other of the finger. These contain micrococci.
In one case of abscess in the neck, which had been forming
for about three weeks, I could find no organisms. The skin was
red over it, and I have entered it in my notes as an acute
abscess. In another case, which I have also in my notes as an
acute abscess, no organisms were found. This was a case of
small abscess in the thigh, in a situation where diseased bone
had formerly existed. The patient positively asserted that the
abscess had only been forming for fourteen days, but it is of
course quite possible that it had existed longer, and had only
begun to point for fourteen days. Nevertheless the man's
jDositive assertion — for I questioned him again after I saAV that
no organisms were present — the redness of the skin, the well-
formed pus cells, and the absence of fatty debris make it
difficult to assert that this was a chronic abscess.
Notwithstanding those two doubtful cases, I am ready to
accept Ogston's statement and to receive it as a law, that if
the pus taken from an acute abscess when opened be examined
after staining, micrococci will always be foimd.
How, then, are my former results to be explained ? By
cultivation, from thirty-two cases of acute abscesses I only got
micrococci in seven instances, and yet we now know that had I
stained the pus I should in all probability have found micrococci
in all.
Well, in my recent investigation I not only stained the pus,
but tried cultivation experiments, and I got much the same
MICROCOCCI IX ACUTE ABSCESSES. 255
results as formerly : in some cases micrococci grew, in others I
got nothing. It seems, as far as I can judge from my facts,
that if the abscess is opened soon after its commencement
micrococci almost always develop. If, however, ten days or
a fortnight or more elapse, these organisms do not as a rule
grow. Why is this ? Simply, I believe, because the organisms
have died.
I made out early in this investigation, and have often con-
firmed it since — sometimes, indeed, to my great inconvenience
— that micrococci very soon exhaust the nutritive material in a
fluid, and that they then fall to the bottom and die, for they
will not grow in any fluid nor increase on the addition of fresh
nutriment. In a flask containing say an ounce of cucumber
or meat infusion, the micrococci grow rapidly, but they do not
live more than three days. Then they fall to the bottom, and
the fluid at the top becomes clear and remains so permanently.
Take a drop from the flask during the first three days and put
it into another specimen of pure cultivating liquid, and micro-
cocci develop readily. After the third day or later, in pro-
portion to the amount of the fluid, no development occurs
whatever one does. The organisms are dead. And so in an
abscess they live as long as they find nutriment, and then they
die and cannot be obtained on attempting cultivation, though
they may still be seen on microscopical examination.
Ogston relates similar facts, though he apparently does not
attach this meaning to them. He remarks that when micro-
cocci are cultivated in flasks containing such fluids as urine,
ascitic, ovarian or hydrocele fluid, blood, &c., the fluid at the
surface remains for months clear, while a slight de2:»osit, which
consists of micrococci, is present at the bottom. He concludes
that the micrococci are growing away from the air, and that
therefore they are anaerobes. This is not the case, for micro-
cocci grow with greater rapidity and luxuriance in pure oxygen
than under any other circumstances which I have yet tried.
The truth, I believe, is, that these organisms were at first not
quite dead, but had very little vigour and soon cea?ed to grow
and died. They were not growing away from the air.
His results in cultivation from abscesses confirm mine, for
he says: 'Often the micrococci grew luxuriantly, sometimes in
25G FERMJ^NTA TIOX.
chains and sometimes in groups, but oftener the experiments
were unsatisfactory, and it indeed happened that the micrococci
which were introduced died altogether.' Now had Ogston put
these two facts together, and had he worked for long with
cultivation, he would, I venture to think, conclude as I do, that
the micrococci which are found in abscesses, but which will not
develop in the cultivating fluid, are already dead in the abscess
and do not die only on removal from it.
The following fact may be mentioned as bearing out this
view : —
Fig. 32 (Plate IV.) was taken from a case of acute abscess
in the groin, which was opened on April 29th. A number of
streptococci will be seen. Nevertheless, a flask of meat and
one of cucumber inoculated at the same time remained quite
barren. A specimen was taken from the same case at the next
dressing, April 30th. There was plenty of discharge in the
drainage tube, but this contained almost no organisms. Had
the organisms been alive on the 29th, they would probably
have been as numerous, if not more so, in the interior of the
drainage tube on the 30th.
So far, then, I conclude, that though micrococci are always
present in acute abscesses, yet if the abscesses be not opened for
some time, these organisms will be found to have died. I shall
not enter here into the question of the relation between
these organisms and the abscesses in which they are found.
The facts are sufficient for my present purpose.
It thus seems, that in certain states of low vitality and in
acute inflammations, organisms may be present in the blood
and tissues of animals. These organisms are generally micro-
cocci.
V. How do organisms get into wounds treated aseptically ?
There are three possible explanations which might be offered : —
1. They come from the blood. 2. They arise spontaneously in
the wound. 3. They come from without through some insuffi-
ciency in the aseptic method.
1. They come from the blood. We have already seen that
organisms are not present in the blood or tissues of the healthy
living animal, but that they may occur in low or inflammatory
states. But a person on whom an o})eration has been performed
MICROCOCCI IN WOUNDS TREATED ASEPTICALLY. 257
aseptically is, after the effects of the chloroform have passed off,
and provided that there has been no great loss of blood, practi-
cally as well as before the operation. There is no inflammation
and no febrile disturbance — the patient, as far as one can
judge, ought to be as able to resist the entrance of organisms
into his blood as before the operation.
If, however, these micrococci did enter the wound from
within, they would do so during the first few days after the
operation ; but if we look at the cases described, and the same
thing can always be found, we see that these organisms do not,
as a rule, enter for several days after an operation — not till the
dressings are but infrequently changed.
In the case of acute abscesses opened early, and in which
the micrococci are still alive, they of com'se exist from the
first ; and so they may occur if for any reason acute inflam-
mation attacks a wound. But that this is their mode of en-
trance in ordinary cases is against all the evidence.
2. As to spontaneous generation. We have discussed that
at such length at various places that I need not enter into it
again. The facts with regard to the absence of organisms
imder certain circumstances and the constant presence of a
particular form when they do occur, together with the points
to be presently mentioned, sufficiently do away with any neces-
sity for considering a view which can only be thought of where
other and more natural modes of origin cannot be traced.
3. We must then search for some mode in which they
might enter through the antiseptic arrangements. These we
may divide into three parts : a lotion in which the various
substances are soaked before being brought into contact with
the wounds ; a spray to purify the atmosphere ; and a dressing
so constituted as to give off carbolic acid to the discharge as it
passes under it.
That the lotion is sufficiently potent to destroy organisms
which come in contact with it, will be very evident to any one
who chooses to examine the subject. If one places a prepara-
tion of actively moving bacteria under the microscope, and
allows a little carbolic acid lotion, 1 in 20, to flow under the
cover-glass, the movements will be seen instantly to cease ;
this, in fact, is the method which I formerly employed when I
s
268 FERMENTATION.
wished to draw moving bacteria with the aid of the camera
lucida.*
That the spray is sufficient has already been shown by a
nmnber of experiments described at p, 2& et seq. (see also the
case of empyema, p. 237).
An attempt has been lately made by Dr. Lewis Stimson ^ to
show that the spray does not act as a germicide, and as his
results have been extensively quoted, I must briefly notice
them here. Three tubes were filled with urine, boiled, and
allowed to cool in the spray and then exposed in it for an hour
and a half, the floor being swept to raise the dust. The tubes
were then closed with plugs of cotton -wool wet with alcohol.
Particles of dust were seen to be caught on the edge of the
tube, and a purified glass rod was used to push them into the
fluid. In one tube in which this was done bacteria developed.
In another case the tube was tilted so as to bring the fluid in
contact with the neck, and here also development occurred.
The third tube was undisturbed and remained pure. In
another set of experiments wide-mouthed beakers were used,
and were exposed for three-quarters of an hour. In all of
these organisms developed. Test experiments showed that
these organisms had entered during the exposure.
These experiments do not, however, seem to be satisfactory.
We are told in the first case that the spray was placed a foot
above and 3^ feet distant from the tubes, and that fifteen
ounces of carbolic lotion, 1-20, were used. During half the
time a board was placed so as to throw the spray back over the
flasks. Now if the flasks were only beneath the spray, a foot
distant from it, during half the period of exposure — the result
cannot be wondered at, for eddies would be produced by the
spray which would drive unpurified dust into the vessels. If,
however, the spray passed directly over the mouths of the flasks
— if these were enveloped by it — it is difficult to conceive that
the spray could have played for so long at such a close dis-
' Dr. Koch has found that the sjMires of Bacilhis Anthracis can resist 1-20
watery sohition of carbolic acid for"a considerable time, though the fully de-
veloped organisms are at once destroyed by it. Micrococci, however, are very
susceptible to the action of this antiseptic.
2 Shown to the New York Surgical Society, November 2/5, 1870.
THE SPRAY AS A GERMICIDE. 259
tance, and that so much lotion could be used without the
entrance into the urine of a quantity of carbolic acid more than
sufficient to render it sterile. But granting that the method
is correct in these respects, Stimson sweeps the floor, raises
large masses of dust luhich he can see, and expects that as
these fall through the spray they will be soaked through and
through, and any organisms in their interior be destroyed ! It
never has been asserted that a mass of filth falling through a
spray can be soaked completely in a moment by tjie acid. We
do not sweep the floors while performing a surgical opera-
tion.
All that I assert is, that under ordinary circumstances the
spray is thoroughly efficient. From this point of view it is in
the niain a question of size of the particles which the spray meets
with. If these are minute and but little compact, they will be
disinfected. If they are large and dense, as will be the case if
the floor be swept during or immediately before the experiment,
one could not expect the spray to soak through them sufficiently
during their transit. There is another way, however, in which
the spray may act on these larger particles — viz. by bedewing
the surface of the wound, and thus keeping up the action on
the dust which began during its transit through the spray. In
fact, the particle of dust already moistened while passing
through the spray, falls into a thin layer of carbolic lotion, and
thus disinfection is completed. As a rule, however, particles of
dust which are small enough and hght enough to float about in
the atmosphere, such particles as are present in ordinary rooms
or wards, will, as far as I can judge, be acted on directly in a
sufficient manner by the spray, for they will not fall straight
through it, but will be carried along with it after being moist-
ened with carbolic acid, and thus time is afforded for the
thorough action of the antiseptic before they reach the wound.
If these organisms got in through fault of the spray, we can
hardly imagine that they would always be micrococci. We
must, therefore, examine the action of the dressing in order to
see if any explanation can be obtained there. We shall see
that it can, and that these organisms do enter on account of
failure of the dressing to fulfil ail requirements for a lengthened
period.
s 2
260 FERMENTATION.
As I have already shown, it is generally at a late period in
the treatment of a case that these organisms appear ; generally
where the dressings have been left on for several days ; or
where the discharge has reached the edge some hours before
changing it ; or, if they occur early, it is when the discharge
which has come through has been considerable, although the
dressing has been changed early; and thus I have been able in
some cases to prevent the entrance of these organisms by
changing the, dressings daily, and, conversely, they are easily
enough obtained in any given case simply by dressing it less
frequently. This will be readily seen from the cases quoted
before.
If such a fluid as milk be tested with the view of deter-
mining the amount of carbolic acid which must be added in
order to prevent the development of organisms, it will be found
that a large quantity is necessary. Thus, they readily develop
in a proportion of carbolic acid and milk, 1-60, and I have
grown them in as large a proportion as 1-54. On examining
the milk while the carbolic acid is being added, a granular pre-
cipitate will be seen to take place. In the same way, if car-
bolic acid is added to serum or white of egg^ a white precipitate
occurs, and here also a large proportion of carbolic acid is
necessary to prevent development. In artificial cultivating
liquids — such as Pasteur's fluid — no precipitate takes place, and
a much smaller quantity of carbolic acid is required to hinder
the growth of organisms. In other words, where carbolic acid
is added to an albuminous fluid, a compound is formed which is
but little antiseptic. So in the case of the antiseptic dressings,
where there is profuse discharge — though the first which comes
through may not be putrescible, yet very soon the carbolic acid
is not present in sufficient quantity to prevent the develo})ment
of organisms ; and, as carbolic acid is very volatile, when a
dressing is left on for several days, a considerable amount of
carbolic acid will have also escaped by evaporation, and thus the
meaning of the following rules of treatment, derived from ex-
perience, becomes evident : ' A dressing must not be too small.'
' The dressing must not be left on longer than twenty-four hours
after the discharge has appeared at the edge.' ' In no case is it
safe to leave a dressing unchanged for more than eight days.'
RELATIONS OF MICROCOCCI TO CARBOLIC ACID. 261
Experience has shown that any marked disregard of these rules
will, in all probability, be followed by putrefaction in the
wound.
But this still leaves unexplained why it is that micrococci
only are found in wounds treated aseptieally. At first the only
hypothesis which I could think of was that micrococci can grow
in j3uids containing carbolic acid in larger quantity than those
in which bacteria can develop. I have accordingly performed
numerous and elaborate experiments to test this view, but I
have been quite unable to find any such difference in the first
instance. An observation which I made in the course of these
experiments seems, however, to furnish the clue to the mystery.
I had previously observed that where one flask was inoculated
with bacteria and another with micrococci in like amount, that
which contained the bacteria was, as a rule, muddy in from twelve
to twenty hours (the quantity of fluid in each flask being 5iij to
3iv), while thirty to fifty hours elapsed before the fluid in the flask
into which the micrococci had been introduced became opaque.
But if carbolic acid, say in the proportion of 1 to 500, be pre-
viously added to this fluid, the result is just the reverse : the
flask containing the micrococci becomes opaque in twenty-four
hours, while that containing the bacteria does not become muddy
till a later period. Following out this line of investigation, I
have found that if micrococci and bacteria be introduced together
into a cultivating fluid containing carbolic acid, the micrococci
will develop rapidly, often to the complete exclusion of the
bacteria. Where no carbolic acid is present, the result is
generally the reverse ; most forms of bacteria grow quickly, the
micrococci being often apparently prevented from developing.
But, it may be said, in the former case the bacteria became con-
verted into micrococci. But if the same bacteria be introduced
into a flask containing no micrococci, bacteria alone develop.
So in the room in which I work, I have never been able,
without the aid of the spray, to transfer micrococci from one
flask to another. For in the latter flask bacteria almost in-
variably developed. But if carbolic acid be previously present
in the fluid, the operation may be done in the most leisurely
manner, with practically a certainty of obtaining micrococci
alone or chiefly in the second flask.
t>fi2 FERMENTATION.
It is thus apparent that though bacteria and micrococc can
grow in fluids containing like amounts of carbolic acid, yet the
micrococci find these liquids more suitable for their growth
than do bacteria ; indeed, they may grow more rapidly in them
than in fluids containing no carbolic acid at all, and therefore,
when bacteria and micrococci fall together into discharge con-
taining carbolic acid, the latter develop with much greater
rapidity than the former, and may thus reach the wound long
before them. If, however, sufficient time be allowed to elapse
before the changing of the dressing, bacteria also may enter the
wound.
One other observation completes this subject. The largest
proportion of carbolic acid in cucumber infusion in which
organisms develop is from 1-450 to 1-500. In one of the
last experiments performed with the view of seeing whether
micrococci could grow in a larger proportion of carbolic acid
th:m that sufficient to prevent the development of bacteria, I
used micrococci which were growing in a fluid in which a small
quantity of carbolic acid was already present. This was done
on April 14th. On examining the flasks on April 15th, I found
one containing carbolic acid in the proportion of 1-400 quite
opaque from the development in it of micrococci, while those in
which a larger proportion of carbolic acid was present remained
clear. On the same day I inoculated from flask 1-400 a new
series containing carbolic acid in the following proportions :
C 1-400, C 1-350, C 1-300, C 1-250. On April 16th, C 1-350
and C 1-400 were quite muddy from the presence of micrococci ;
while C 1-300 and C 1-250 were clear. That afternoon, afresh
series, C 1-350, C 1-300, C 1-250, C 1-200, was inoculated
from C 1-350. On April 17th, C 1-300 and C 1-350 were
muddy. Here the limit seems to have been reached. For
though I have obtained slight development in carbolic acid
and cucumber 1-275 and 1-250, this is not vigorous. As the
micrococci grow in larger proportions of carbolic acid, they
become much larger, and the grouping and mode of growth
described by Mr. Lister are more evident.
The facts then seem to be that the discharge, when profuse,
or when it arrives at the edge of a dressing which has been left
on for some days, does not coatain sufficient carbolic acid to.
MICROCOCCI IN WOUNDS TREATED ASEPTICALLY. 263
prevent the development of org-anisms in it ; that micrococci,
which I find to be more abundant in the ward atrtiosphere
than bacteria, find this a particularly favourable medium for
growth ; and that as they grow they increase in vigour, and
become more able to live in fluids containing a larger propor-
tion of carbolic acid, and thus, if time be given them, they will
eventually reach the wound.
Since these investigations were made, I have been able to
demionstrate the spread inwards of organisms under a gauze
dressing. Look for a moment at Case 12, p. 241. A specimen
of the discharge was taken on March 31st, from the gauze
dressing near the edge, and was found to contain micrococci
and bacteria. No organisms had, however, as yet reached the
wound (see Fig. 18, Plate III.). This dressing was removed, a
new dressing applied, and the organisms had to begin again
at the edge. Fig. 19, taken from the dressing near its edge,
and Fig. 20, taken from the drainage tube four days later,
illustrate the same thing. Here also the organisms were pene-
trating inwards under the dressing, but had not yet reached
the wound, and it was not till two days later that the first
traces of micrococci appeared in the wound.
The same thing is demonstrated in Case 13, p. 242. Here
Fig. 21, Plate III. is a specimen taken from the gauze near the
wound, and it contains a few micrococci : they had not, how-
ever, reached the wound, and did not do so till some days later.
Then, again, I have been able to keep out these organisms
simply by dressing more frequently so as to anticipate them
before they reach the wound, as may be seen in the case of
empyema, &c. And Dr. Ogston does not find micrococci in his
aseptic cases, because he dresses much more frequently than
Mr. Lister, never allowing the discharge to appear at the edge
of the dressing at all.
It will not, however, be always necessary that the discharge
should appear at the edge, for if a dressing be left on for several
days sweat accumulates under it, and will serve the same pur-
pose as the serous discharge in conducting organisms inwards.
At the same time it is possible that organisms may oc-
casionally enter the wound from the blood, especially in the
conditions of interference with the healthy state which were
■Jdi FERMENTATION.
formerly alluded to ; and it is also possible that they may enter
from fault in the aseptic precautions, though I think this must
be exceedingly rare. For it is difficult to imagine that in the
latter case only micrococci would get in ; indeed, in faulty ex-
periments with cultivating fluids, it is almost invariably some
form of rod-shaped organism which appears.
CHAPTER Xlir.
ANTISEPTIC SURGERY.
Complete definition of antiseptic surgery. Varieties of antiseptic surgery.
Tkeatment by antiseptics : Carbolic acid — objections to it : Chloride
of zinc: Boracic acid: Sulphurous acid: Chlorinated Soda: Alcohol — •
Hutchinson's method : Terebene and Sanitas — Bilguer's method — Neu-
dorfer's salicylic powder. Free drainage as an antiseptic method.
Irrigation and immersion. Open method: Modes in which it acts
antiseptically : Bartscher and Vezin's method : Burow's method : Rose's
modification. Healing by scabbing : Methods of forming a crust :
Bouisson's ventilation method : other modes. Gtjerin's cotton-wool
DRESSING. Modes in which the destructive action of the
tissues on bacteria is assisted. Why does not fermentation alwaj's
occur in the blood in wounds in which organisms are present ? Best
practical methods. Conclusions.
We have now arrived at the end of our discussion as to what
are the particles which cause putrefaction ; what are the exact
enemies with which we have to contend in attempting to
prevent putrefaction. We have seen that it is from particles
falling into fluids or on tissues that organisms develop. We
have seen that it is only after the access of particles from the
outer world to such fluids and tissues that fermentations occur,
and we have satisfactorily demonstrated that the particles
which cause fermentations and those which give rise to organ-
isms, are one and the same — in other words, fennentations are
due to the growth of organisms in fluids or tissues. We have
also seen that these same laws, with one exception, to be pre-
sently mentioned, hold good when the fluids or tissues are con-
fined in the living body, just as when they are in flasks, viz.,
that the particles which cause putrefaction and other fermenta-
tions only rarely enter such substances through the circulation,
but generally reach them directly from the air or from sur-
rounding objects ; that so long as an animal is healthy, dead
L'GG ANTISEPTIC SURGERY.
fluids or tissues may remain uufermented in closed cavities in
the body, and may even entirely disappear, but that as soon as
atmospheric air with its dust is admitted, organisms develop,
and fermentations occur. We are now therefore able to take a
much wider view of the meaning of the term ' Antiseptic Sur-
gery ' than is generally done. It is no longer surgery which
only excludes the causes of putrefaction ; we may now include
under the term all those methods of ivound treatment in
which, luittingly or othertvise, the growth and fermentative
action of the lower forms of organisms {bacteria^ are m^ore or
less impeded.
When we come to look at the numerous methods of wound
treatment from this point of view, we shall see that there is
perhaps none at present employed, with the exception of the
poultice dressing so much lauded by Mr. Savory, which does
not in some way or other, however imperfectly, interfere with
the growth and fermentative action of bacteria, and which does
not owe its chief virtues to that cause.
I shall not enter into details on all these methods, for their
number is legion, but I shall discuss the modes in which this
interference with bacteric action may be carried out under
several headings, and indicate briefly the principles which
ought to guide the surgeon in carrying out one or other
method.
The antiseptic methods which merely interfere with the
development and fermentative action of organisms on the fluids
and tissues in wounds, and which do not aim at their total ex-
clusion, may act on various principles.
1. By the addition of various antiseptics to the discharge,
either in the wound, or after it flows out, this discharge may be
rendered an unfit soil for the development of organisms. — Use
of antiseptics.
2. The discharge may be allowed to flow away so rapidly as
not to have time to undergo fermentation to any extent in the
wound itself. — jPree drainage.
3. This removal of the discharge may be facilitated by
washing it away constantly with water alone, or with water
containing antiseptics. — Treatment by irrigation or by water
buih.
TREATMENT BY ANTISEPTICS. 267
4. By freely exposing the discharge to air evaporation
takes place, and the fluid becomes too concentrated to permit
the growth of bacteria, while, at the same time, by supplying
these organisms with plenty of oxygen, they have no necessity
to break up the albuminous compounds in their search for
oxygen, and thus, as shown by Pasteur, their fermenting power
is diminished. — Open treatment.
5. By keeping the parts at perfect rest and by operating
only when the patient is in good health, the tissues and the
blood are in such a state as to resist the development of bacteria
in the thin layer of lymph between the cut surfaces, and
union by first intention thus occurs. This is best carried out
hy perfect rest and accurate apposition of the cut surfaces.
Healing hy scabbing acts on the last two principles.
Although these various methods may be described as acting
on these different principles, yet there is no hard and fast line
between one and the other. Indeed, at the present day advan-
tage is now constantly gained from the use of the various
principles combined — as, for instance, by the employment of
free drainage, antiseptic irrigation, cS:c., in the open method.
As these methods are so very numerous, and as they are gene-
rally modified by every surgeon who employs them, few indeed
using them on the true principle, I think it will be best
merely to make a few remarks under each heading, and then
when we come to the historical part we shall be able to fill up
blanks in the following description.
I. — Methods hy ivhich various Antiseptics are added to the
Discharge, so as to hinder the Developjment of Organisms
in it.
What are the best antiseptics to use for this purpose ?
Carbolic acid is the one most frequently employed, but, in
my opinion, it is by no means the best in this instance. We
have already seen that in vegetable infusions, where carbolic
acid is present in the proportions of 1-200 to 1-250 all further
growth of organisms is prevented, but that in such fluids as
serum, milk, pus, &c., the acid forms a compound with the
albumen, and a much larger proportion is required. Thus, in
•2GS ANTISEPTIC SURGERY.
milk, carbolic acid in the proportion of 1-54 is just enough
to prevent development. In accordance with this fact, a very
strong solution would be required in the case of wounds, or it
must be added in large quantities, in order to prevent the
development of micro-organisms.
And so my own experience of carbolic acid as a disinfectant
in the form of a 1-40 watery solution in putrid cases is un-
favourable, while, on the other hand, if 1-20 carbolic acid be
used, it is very irritating, and interferes with healing. In-
jected once or twice a day, the latter destroys the superficial
granulation cells, and produces a thin slough in which bacteria
develop, and from which it is very difficult to dislodge them.
Then its poisonous qualities are objectionable, and are of
course much more evident when the acid is injected into
wounds or abscess cavities than when used in the manner de-
scribed in the chapters on aseptic surgery.
Further, Dr. Wilhelm Hack,^ in a paper on the power of
absorption by granulations, has demonstrated that granulations
treated with carbolic acid possess many of the qualities of a
recent wound as regards absorption. For instance, apomorphia,
which was only absorbed by wounds treated with water dressing
during the first twelve hours, was readily absorbed at any time
by granulating wounds treated with carbolic acid ; and therefore
in the absence of information to the contrary, I should fear
that some of the poisonous products of putrefaction might be
absorbed with like avidity. Hence, I do not like carbolic acid
unless it is used aseptically.
Chloride of zinc applied to the cut surface has been already
alluded to. A single application has the remarkable property
of preventing putrefaction in a wound for some time after an
operation ; sometimes, indeed, till granulation is nearly com-
plete. It is further useful, according to Hack's experiments,
in that the slough caused by it does not permit the absorption
of substances from the wound. When used in the treatment
of wounds, a dilute solution (1 or 2 grs. to the ounce of water)
is employed.
Boracic acid is too weak an antiseptic to be of much service
' Ueber das Resorpt ionsvermogen granulirendcr Fliichen. L ipzig, 1879.
TREATMENT BY ANTISEPTICS. 269
as an injection, but the boracic ointment and the boraeic lint
act well as dressings.
One of the best antiseptic lotions is made with sulphurous
acid. This is a powerful germicide. It is also non-irritating
and perfectly free from any poisonous qualities. It is used as
a solution which is made by mixing together equal parts of
the sulphurous acid of the pharmacopoeia and water or glycerine.
This may be still further diluted if necessary.
The chlorinated soda solution is mentioned by Dr. Cabot as
standing next to 1-20 carbolic lotion in rapidity of action on
bacteria. The strength generally employed is 5ss. to 5J of
water.
Alcohol is not a bad antiseptic, but in order to be effectual,
it must be used strong. It has a further advantage, for Dr.
Hack has shown that gi-anulations treated with alcohol do
not absorb at all or only very slightly ; and to this may be
attributed, to some extent, the favourable course of the cases
in which wounds are simply washed out with an alcoholic solu-
tion, and a rag, dipped in the same solution, applied outside.
Mr. Jonathan Hutchinson, more especially, has had remark-
ably good results from the use of alcohol. His method is as
follows : — Having carefully arrested all haemorrhage, chiefly by
torsion, he washes out the wound with pure spirit. He then
carefully arranges drainage tubes at the most dependent parts,
and stitches up the rest of the wound. Thin compresses soaked
in a lotion composed of 6 parts of absolute alcohol, a half part
of liquor phmibi, and 16 parts of distilled water, are now ap-
plied. These compresses are kept constantly moist, either by
a nurse or by means of a drop irrigator. The lint is changed
daily. In the treatment of important cases, such as com-
pound fractm'es and dislocations the rule observed is, never to
allow the skin to become warmer than natural. His wounds
generally heal by first intention, and septic poisoning is very
infrequent.
In some of these cases no doubt the wound may be aseptic
from first to last. To apply an antiseptic to a wound, to stitch
up immediately, and then keep an antiseptic dressing con-
stantly applied, is really to operate more or less aseptically,.
and I believe, with regard to INIr. Hutchinson's cases, that this
270 ANTISEPTIC SURGERY.
partly explains the good results — the wound being aseptic, at
least for a time. Then Hack's results have a strong bearing
on these cases, for absoq^tion does not take place readily.
Mr. Hutchinson is also very particular to have free drainage,
which powerfully helps to maintain the aseptic condition ;
and lastly, he carefully selects the cases for operation, only
operating, unless in cases of necessity, where the patient
is in good health. This selection of cases is a thing not
necessary and not done where complete aseptic treatment is
employed.
The method which I should think was the best, acting on
this principle, is the following; it is practically what Mr.
Lister employs with excellent results, only I would reject the
carbolic acid. After the wound has been made, and before any
stitches are inserted, the raw surface ought to be thoroughly
sponged over with chloride of zinc solution (40 grs. to the oz.
of water). In the case of operations on the extremities, this
is best done before the tourniquet is relaxed,- so as to ensm-e its
thorough application, for otherwise the blood would wash away
the solution or dilute it before it has had time to act. Silver
wire stitches are then inserted — special care being taken to en-
sure free drainage, by the use of large drainage tubes. As a
dressing in the first instance, till the bleeding has stopped,
several layers of wet boracic lint (wet in boracic lotion) are
applied.
On the day following the operation, the lint is removed, the
surface of the wound is thoroughly cleaned with sulphurous
acid or chlorinated soda lotions, or with Hutchinson's lotion,
and the drainage tubes are washed out with the same, though
not removed. The dressing is now a narrow strip of the sali-
cylic, eucalyptus or full strength boracic ointments, thinly but
evenly spread on calico, and outside this, overlapping it in all
directions, one or more broad layers of boracic lint.
On the second or third day, the drainage tube is removed,
and is washed in 1-20 carbolic lotion, the wound being then
syringed out with the sulphurous acid or other lotion. After a
day or two the ointment over the line of incision is changed to
the half-strength boracic, or if salicylic or eucalyj)tus ointment
was used, they are retained. These di-essings are changed daily
FREE DRAINAGE, 271
at first, but when the discharge diminishes, they may be left
for two days.
Terebene and sanitas are remarkably good applications
where the smell is bad.
The results of this treatment are of course not so perfect as
those of the aseptic method, for, however carefully one washes
out the wound, there are pouches in it into which the fluid does
not enter, and pieces of slough cannot of course be disinfected.
Thus, prolonged suppurations may occm-, caries may continue
without tendency to cure, and even accidental wound diseases
(pyaemia, &c.) attack the patient.
With regard to the use of chloride of zinc, I ought to say
that it is well not to apply it to wounds which must, if pos-
sible, heal by first intention, as, for instance, in incisions about
the lips or face.
It was on this principle, as we shall see, that Lemaire em-
ployed carbolic acid and coal tar ; and his results, though very
good, by no means correspond to those obtained by strict aseptic
treatment.
It was also on this principle that good results followed the
use of balsams of various kinds in olden times. The most re-
markable example of the success of such attempts at rendering
the wound secretions incapable of putrefaction by the use of
balsams, was that of Bilguer in the last century. No doubt
where the wound is shallow, and possesses few recesses, and
where the balsam or other antiseptic employed fills up these
recesses, we have really an aseptic treatment and an aseptic
result.
By sprinkling powdered salicylic acid on wounds till no
more fluid passes out, Neudorfer manufactures a paste under
which he says that healing may occur without suppuration.
II. On Free Drainage as an Antiseptic Method.
I have already discussed the main principles of drainage
under the head of aseptic sui'gery. It is quite clear that, if dis-
charge flows away as fast as it is formed, there can be no marked
development of bacteria or of their products. The free drains <'-e
272 ANTISEPTIC SURGERY.
of a wound from which organisms are not from the first excluded
is therefore of the utmost importance. I have already de-
scribed the use of india-rubber tubes, and I have referred to
catgut and horse-hair. Since, in a wound not treated asepti-
cally, fermentation, most probably followed by suppuration,
generally occurs in the track of the drain, we must provide such
a drain as shall permit the free escape of pus. Now, neither
horse-hair nor catgut can drain pus, and, therefore, a tube of
some kind or other must be used. This may be an india-
rubber one, or it may be made of various kinds of metal, per-
forated at its sides, and cut flush with the surface. The tube,
of whatever material, must be removed from the wound at each
dressing and washed with a strong antiseptic lotion, say 1-20
carbolic lotion. If this be not done, portions of decomposing
tissue, &c., remain inside the wound, and become more and
more putrid till very soon they become caustic.
Where the wound is not treated aseptically, the principle of
having the most dependent opening possible must be carried
out to the full.
III. Irrigation and Immersion.
The principle of free drainage is never of course used alone,
other principles act along with it. Of these, one of the most
satisfactory is that in which the discharge is not merely allowed
to flow away, but is washed away, and the further addition to this
principle of adding an antiseptic to the water used for the irri-
gation and of thus keeping the wound constantly bathed in an
antiseptic fluid. The latter is the form in which irrigation and
the water bath are now always employed, viz., by the use of an
antiseptic solution.
Irrigation is, as a rule, only practicable on the extremities,
though it may be carried out on the trunk. P'or the latter,
however, the continuous water bath is the most convenient.
The wounded part having been arranged at perfect rest, a
sheet of mackintosh is fastened to the limb, and so arranged
that the fluid flowing from the wound shall be conducted to a
tub ; the vessel containing the fluid is fixed at a considerably
higher level than the patient. The form of irrigator most
IRRIGATION AND IMMERSION.
273
generally used at the present time is Esmarch's. This consists
of a cylindrical leaden or zinc vessel, which has a ring at its
upper part to enable it to be affixed to the wall. From the
side of this vessel, close to its bottom, a tube passes, and to the
end of this tube is fastened a long piece of india-rubber tubing
with a nozzle at its end. This nozzle is arranged so as to
direct the fluid into the deeper parts of the wound. The fluid
used is generally some weak antiseptic solution, such as chlori-
nated soda or sulphurous acid, or boracic acid.
A very good apparatus can be made in an emergency (accord-
ing to Thiersch) by knocking the bottom out of a champagne
bottle, and having the tube for conveying
away the fluid passed through the cork. The
bottle is inverted, filled with the solution,
and fastened to the wall. The fluid used
may be tepid or cold, as we shall see later.
There is no advantage in using it very cold,
as recommended by some.
Where the fluid is dropped on to the
wound, it is well to place a piece of lint
over the part where the drop falls, to pre-
vent the constant irritation caused by the
concussion. The skin in the neighbour-
hood of the wound ought to be coated with
palm oil, in order to prevent maceration.
The continuous bath is either a bath in
which the whole patient can be immersed,
or one in which the wounded part alone is
placed. There are numerous methods of
doing this, and the references to these will
be given in the history of the subject.
The advantages of the treatment by con-
stant irrigation are, that the discharges are removed as fast as
they form, and at the same time, where an antiseptic is em-
ployed, the part is kept constantly sweet. Thus, where the
cavity is small and uncomplicated, there may be a truly aseptic
state of affairs.
At the same time, where tepid water is used granulation is
favoured, while pain and nervous irritation are very much
T
Fig. 73. — Thiersch's
champagne bottle
irrigator.
274
ANTISEPTIC SURGERY.
diminished. Fartlier, the parts are kept at absohite rest, the
necessity of moving them in order to change dressings, &c.,
being avoided.
As an antiseptic means, 1 should think that satisfactory
irrigation is lietter than the continuous water bath, for in the
latter there is not the same constant change of fluid, nor the
same washing away of the discharge.
Fig. 74.— Aerangemest fou iurigation in the uppek limb.
(After Esmarch.)
The favom-able results of constant irrigation in preventing
septic diseases are very remarkable, and, in this respect, it
probably stands next to strict aseptic treatment.
The disadvantages of these methods are for the most part
the sodden state of the wound and the consequent cedematous
condition of the granulations, the constant state of unrest of
the wound and the inconveniences attending the application of
the method. For the first reason they are discontinued when
granulation is complete and has filled up the deeper jjarts of
the wound, and when the time for blood poisoning has passed.
IRRIGATION AND IMMERSION.
275
That the good results of irrigation and immersion are
not due to mere maintenance of temperature, as has been
Yir,. 7.".— Arrangement for irrigation in the lower limb.
(After E::maic)i.)
supposed, is shown by the results of M. Gnyot with his
incubation method. Here the wounded part was enclosed in
Fig. 76.— Apparatus for continuous immersion.
(After Esmarcli.) (For the e.xtremities.)
T 2
276 ANTISEPTIC SURGERY.
an incubating apparatus, and kept permanently at a high
temperature. This method, though much lauded for a time,
really seems to have favoured considerably the development of
septic diseases.
IV. Concentration of the Fluids, and their Admixture
ivith Oxygen.
The method of treatment which has been the greatest
stumbling-block in the way of the acceptance of the principles
of antiseptic surgery is the open method, for surgeons have
been unable to see how the success of this method could be
reconciled with the germ theory of putrefaction. They have
looked on it as the antithesis of aseptic treatment, as acting
on the very opposite principle to that on which the aseptic
method is based. And yet, when we come to consider the
matter in the light of the true principles of antiseptic surgery,
we find that the open method is an advanced method of
antiseptic treatment. Of course other principles, such as that
of perfect rest and free drainage, also tell markedly in this
ease.
I have stated that this open method acts antiseptically in
two ways, and these I must now briefly consider.
1. It acts antiseptically in that the discharges dry up, and
become more concentrated, and thus become unfit soil for the
growth of bacteria.
Tliat concentrated fluids are not suited for rapid development
of organisms is well known. Thus Pasteur pointed out that
organisms could not grow in sugary solutions which had become
concentrated. This fact is made use of in the arts, in the pre-
servation of fruits. Sugar is added in large quantities, and
then the fruits can be kept for an indefinite length of time.
It is not that the sugar is an antiseptic killing the organisms, it
is merely that by its presence in large amount the fluid is
rendered unsuitable for development.
The same pi-inciple is made use of in preserving milk. The
milk is evaporated to one-third of its original volume, and a
considerable quantity of sugar is added to it. Without the
addition of the sugar, the condensed milk may be kept for a
THE OPEN METHOD. 277
considerable length of time without the appearance of organisms
in it ; with sugar it may be kept indefinitely.
The same is the case with other albuminous fluids such as
the discharge from wounds. Concentrate pus, and it will be
found that organisms develop in it only with difficulty.
Then we know the contrast between cases of dry and moist
gangrene ; how in the latter putrefaction rapidly occurs, or, in
other words, organisms rapidly develop, while in dry gangrene
putrefaction does not occur, i.e. organisms cannot develop.
The same was seen in Cazeneuve and Livon's experiments
on minary bladders, mentioned before at p. 37. In that case
organisms could not develop in the wall of the bladder, because
the fluid was constantly evaporating.
2. In the open method another antiseptic advantage is
gained by the free admission of oxygen to the discharge.
Some very remarkable effects of oxygen in retarding putre-
factive and other fermentations were published long ago by
Pasteur. He pointed out that if a sugary solution were freely
exposed to air in a thin layer, the yeast plant, though it grew
luxuriantly, caused very little fermentation. On the other
hand, if oxygen were excluded, only a small development of
the yeast cells was necessary for fermentation. And he has
bhewn that other plants besides the yeast plant can cause
alcoholic fermentation, if only they are deprived of free oxygen.
With regard to putrefaction he has brought forward similar
evidence. The organisms which cause putrefaction are, according
to him, incapable of living in the presence of oxygen. If a
putrescible fluid be freely exposed to the air in a thin layer,
putrefaction does not occur, at least not for a very considerable
time. Just as in the butyric fermentation, oxygen not only
interferes with the fermentative process, but actually destroys
the bacteria which cause it. Hence the free exposure of a
putrescible fluid to the air results in comparative freedom from
putrefaction, partly because the oxygen interferes with the
development of fermentative changes, and partly because the
oxygen directly kills the putrefactive bacteria.
There are two methods of wound treatment which action the
principles alluded to above. The first is that introduced by Bart-
scher and Vezin, and carried out in the following manner : ' After
278 ANTISEPTIC SURGERY.
all bleeding vessels have been tied, and after the stump has
been cleansed from blood clots by means of a sponge and cold
water, the patient, for whom two beds are provided close to each
other, is put to bed, the stump is laid on a soft pillow, and over
it a piece of gauze or linen is loosely placed in order to keep out
the flies, the whole stump being freely exposed to the air.' At
the morning visit, the surgeon pushes his hand under the stump,
raises it, removes the pillow and applies a new one, or lifts the
patient on to the other bed, without further cleansing of the
wound. In this method all attempts at union by first intention
are given up.
Bi:u-ow of Konisberg published his method in 1859. He
attempted to obtain primary union as far as possible. This he
did by bringing the surfaces of the wound into contact after a
few hours by means of strips of plaster applied over part of the
surface, all other dressings being avoided.
Rose, whose results of open treatment have been specially
published by Kronlein, adheres to Bartscher and Vezin's method,
with this exception, that he daily washes out the wound with
some antiseptic lotion. Crusts are removed, as they are never
complete enough to prevent putrefaction, and only cause tension
by their presence, and indeed protect the discharge underneath
from the action of the air, or of the antiseptic lotion. Eose
farther ventilates very freely, so as to have a plentiful supply
of air to the stump. He employs this method in all wounds,
except those on the face, where union by the first intention
is desirable.
The open method pure and simple is that introduced by
Bartscher and Yezin ; for here, while the discharges are allowed
to flow away freely, they are left to the unaided action of the air.
The antiseptic effect of this method is no doubt increased by
the addition of intermittent antiseptic irrigation.
Burow's method cannot act nearly so perfectly, for in it dis-
charges must accumulate in various parts of the wound, and
they are therefore not so conveniently placed for thorough action
of the air.
Among the objections to these methods are the following ;
in all, except Burow's, union by first intention cannot possibly
occur, indeed no attempt is made to obtain it; as a conse-
HEALING BY SCABBING. .279
quence of this, a long time is required for healing, while a larger
scar is obtained ; the frequent formation of scabs and the con-
sequent tension also cause great annoyance.
Closely allied to the open method stands healing hy scab-
bing. This may be brought about chiefly in two ways. The
crust may either be allowed to form naturally, or its formation
may be aided by artificial means.
This healing by scabbing acts in two ways. In the first
place, the first principle of the open method of treatment comes
into play ; the discharge dries up and becomes an unfit soil for
the development of organisms. In the second place the fluid
underneath it is in such a thin layer that the living tissues in
the neighbourhood prevent the development of organisms in it.
Of course in many cases no living organisms would be there to
develop, for the scab would form an absolute pi'otection against
their entrance.
The natural formation of the crust can only take place effi-
ciently in small wounds, and only exceptionally where cavities
and recesses are present. For in larger wounds, as we have
seen, there is too much discharge for a sufficiently rapid and
thorough formation of a crust ; and if the crust is not perfect
and rapidly formed, putrefaction takes place underneath it, while
at the same time, by confining the discharges, tension and ulcera-
tion result in place of healing.
But though this natural formation of a crust cannot be trusted
to in most cases, yet by artificial means a satisfactory one may
be obtained.
The method in which this was done by Bouisson, was by
blowing air on to the wound, and thus drying the discharges.
This method will be described in the historical part of this work.
The most common modes are by the application of various
powders, such as starch, alum, flour, &c., to the discharge, so as
to form a paste. The best substance which can be employed
in this manner is powdered salicylic acid, as recommended
by Neudorfer, and mentioned before under ' Treatment by
Antiseptics,' This is sprinkled on till no more fluid exudes, and
it combines the advantages of a thorough crust with those of
an antiseptic dressing.'
' For clolails of tlicsc various melliods, sec tlie historical part.
280 ANTISEPTIC SURGERY.
Other attempts have been made to produce a scab by the
application of various caustic substances to the surface of the
wound. The crust so formed, containing as it does a strong
caustic, is unable to undergo putrefaction ; and where the inflam-
mation caused by the application is not too great, and does not
lead to accumulation of fluid under the crust, an excellent result
is obtained. In this case, as no organisms are present under
the crust (they were destroyed by the caustic), and as the firmly
adhering crust prevents their entrance, we have the typical
aseptic result — healing of an open wound without suppuration or
granulation. There are, however, various objections to this
method of crust formation, the chief of which is the loss of
substance involved in the process, while the same disadvantages
are present as in the open method proper, viz., slowness of heal-
ing and a large scar.
Closely allied to this method of crust formation is that in
which the crust is obtained by the application of the actual
cautery.
Crust formation is seldom suitable unless in the case of
superficial wounds without recesses or cavities, for, if these are
present, an opportunity is given for the occurrence of tension
under the crust. It is a method by no means easy or universal
in its application. Where it is employed I should recommend
the use of Neudorfer's method, viz., the formation of a crust by
the aid of salicylic acid powder.
Alphonse Gueriri's Cotton-wool Treatment acts partly on
the first part of the principle of the open method, but it hardly
comes into the category of antiseptic methods.
As originally used, the wound was simply washed with water,
and a large mass of cotton-wool applied around it, and firmly
bandaged on.
At present the wound is washed with some antiseptic lotion,
and layers of cotton-wool, containing camphor powder sprinkled
in it, are applied. The deeper layer consists of wool moistened
in carbolic lotion.
More details of this method will be found in the historical
part ; but I may mention here a point wliich Gruerin considers
of great importance. The dressing should not be applied or
changed in the ward, but in a theatre or side room, and the
PERFECT REST. 281
packet of cotton-wool should not be opened till the time of
application of the dressing. No doubt these precautions may
prevent some infective material present in the ward atmosphere
from settling on the wound or on the cotton-wool, but it is only
a chance that such will be the case.
This method can hardly be called ' antiseptic ' in the sense
in which we have used the word, for the antiputrescent princi-
ples on which it acts are not very powerful. As the result of
these dressings, the discharge becomes thick and concentrated,
and not a very good medium for development of organisms.
Nevertheless this concentration of the discharge cannot occur
to anything like the extent which takes place when it is left
freely exposed to the air. The second principle on which it
acts is that it ensures absolute rest to the wound. By means
of this rest the granulations are not lacerated, and neither
bacteria nor their products can be admitted into the body.
This however is a principle relating to infective disease, a sub-
ject which we have not mixed up with the true antiseptic
principle, which is solely that of preventing putrefaction in the
wound.
Gruerin's method cannot be recommended except in some
exceptional cases of disease of joints with sinuses, and even
here the retention of the putrefying discharges, and the conse-
quent irritation, render it of very doubtful value.
I have already described the aseptic applications of pure
cotton wool at p. 141.
V. Assist the destroying Action of the healthy living Tissues
on Bacteria.
This principle may be aided in two ways, viz., by perfect
mechanical rest, and by attention to the general health.
By perfect mechanical rest, when the tissues are in perfect
health, and the blood clot is undistiurbed, the tissues and clot
may be kept in such a state as to resist the development of
organisms. This method, though without recognition of the
antiseptic principle, has been long practised, and of late has been
specially advocated by Sampson Gamgee.'
' On the Treatment of Wounda, 1878.
282 ANTISEPTIC SURGERY.
It is, of course, a well-known fact that, without any antiseptic
appliances at all, wounds, more especially about the face, heal
frequently by first intention. How can this take place if blood
or lymph, exposed to the air, putrefies as the result of the
access of organisms ? For, during the operation, organisms
enter the wound both as dust from the air and surround-
ing objects, and also from the water in which the sponges are
soaked. There is also between the cut surfaces a layer of blood
or lymph (which, however, must as a rule be very small in
amount, otherwise healing by first intention does not occur)
which, if it were exposed between two plates of glass, would
probably putrefy in a short time. How is it that union by
first intention can occur under these circumstances ? How is
it that the blood does not putrefy between the cut surfaces
of a wound ?
Well, to use Mr. Lister's forcible arguments, the fact is that
a thin layer of blood, although containing numerous causes of
putrefaction, does not as a rule putrefy if it be placed between
two healthy living cut surfaces. Or, to state the fact in an-
other way, these organisms, which are certainly present, cannot
develop in a thin layer of blood or lymph placed between two
healthy living freshly cut surfaces. Or, to state the same fact
differently (taking into consideration the different results when
the same layer of blood or lymph is placed between two plates
of glass), the living tissues^ tvhen in a healthy state, have the
power of preventing the development of organisms in their
immediate vicinity.
I have already had occasion, in a former part of this work
(p. 252), to point out that if into a healthy living animal a
small quantity of ordinary bacterial fluid be injected, the
bacteria lose their vitality and disa})pear. I have shown how
organisms cannot be found in the living healthy body (I except
here of course specific pathogenic organisms, such as bacillus
anthracis), unless a considerable amount of their products be
introduced along with them. On the other hand I demon-
strated how, if the animal were out of health, organisms could
live in their blood and tissues much more easily. The same
is the case in union by first intention. If the part be of
high vital power, and in a healthy state, and if there be an
ANTISEPTIC ACTION OF LIVING TISSUES. 283
extremely small amount of blood or lymph between the cut
surfaces, union by first intention will almost certainly occur.
If the part become inflamed, or if the patient be in a weak state
of health, union by first intention, without aseptic means,
becomes a matter of great uncertainty.
Traube and Grscheidlen ^ have likewise found that blood
taken with precautions from a healthy living rabbit into which,
24 or 48 hours previously, 1^ c.cm. of bacterial fluid had been
injected, could be kept for months without undergoing putre-
faction.
And, further, the facts which I have already mentioned,
that the blood and tissues of healthy living animals do not
contain Jiving organisms, shew sufficiently that they have the
power of destroying them, for otherwise there are frequent
opportunities for the entrance of these into the circulation.
This same principle was made use of by jNir. Lister in his
experiments for obtaining unboiled urine (see p. 36). He
simply washed the glans penis, and the meatus urinarius. He
did not wash out the urethra at all. The urine passed in this
way remained absolutely pure, showing that no organisms were
present in the urethra. And yet the urethra contains mucus,
putrescible outside the body, and there is sufficient time
between the acts of micturition for bacteria to spread quite up
to the bladder (this was experimentally determined by Mr.
Lister); nevertheless they do not penetrate any distance into
the urethra. In other words, they cannot develop in this
putrescible mucus, when it lies between two healthy living sur-
faces. Or, to state the fact otherwise, the healthy living tissues
have somehow or other the power of preventing the develop-
ment of organisms in their immediate vicinity.
Now blood clot itself may be looked on as a tissue, though
one which is of very low vitality. That it is a tissue is well
shown by Mr. Lister's experiments on coagulation of blood ; for
he found that a tube or cup of blood clot acted in the same way
as regards the prevention of coagulation as the living walls of
the vessels. He further found that movement of the clot
leading to its laceration destroyed its vital power as a tissue.
In the ' Dublin Medical Journal ' for August 1879, Mr. Lister,
after referring to this subject, mentions the following facts: —
' Loc. cit.
284 ANTISEPTIC SURGERY.
' I have found, in experiments not yet published, that you
may put into such purified glasses' (containing pure blood)
' drops of water of considerable size ; and although every
hundredth of a minim probably contains a septic organism, and
although the blood that flows into each glass is mixed with this
septic water, yet the clot there formed, if protected from any
other source of disturbance afterwards, remains sweet and pure
for weeks together, proving that even outside the body the
blood clot has the power in itself of resisting the development
of septic organisms — a most important truth.' After applying
this principle to union by first intention in cases of amputation,
he says : ' But suppose such a stump attacked by muscular
spasm churning up the blood clot, then the septic particles
would develop, and then you would have putrefaction and septic
suppurations, so that without antiseptic treatment in this kind
of case, you are at the mercy of perfect immobility ; and, as I
have said before, even with the best means, you cannot secure
this.'
In his recent address at Cambridge, Mr. Lister refers to
similar facts, but as he has not yet published them, and as the
accounts given in the journals are very garbled, I cannot refer to
them. It seems however that he confirmed the experiments
just mentioned, and found that blood clot, when kept perfectly
undisturbed, did not putrefy, even if 4 drops of tap water were
placed in the flask before the blood was introduced.
A very interesting experiment bearing on this subject is
mentioned by John Hunter in his paper on * The living principle
of the blood.'
After pointing out how fresh and living eggs resist putre-
faction, and referring to various facts which he thought were
indications of the existence of a living principle in blood, he
narrates the following remarkable experiment, showing that the
blood of young jjersons resists 'putrefaction longer than that
of old people ; in other words, that the blood of young persons
has greater vital power.
' June 24th. — Some blood was taken from a woman twenty
years of age, and its surface, after coagulation, was covered with
un inflammatory crust.
' On the same day some blood was taken from a woman at
BLOOD CLOT DESTROYS MICRO-ORGANISMS. 285
sixty, when the crassamentum was also covered with an inflam-
matory crust.
* These quantities of blood were set by.
* The blood from the old woman putrefied in two days. That
from the young woman kept quite sweet till the fifth day, when
it began to smell disagreeably ; in this state it continued two
days more, and then emitted the common odour of putrid blood.
' Several experiments were made in the course of the
summer of a similar nature with the last, in all of which it
appeared that the blood from young people kept longer sweet
than that which was taken from the old.'
That healthy blood clot can resist putrefaction so long as it is
kept at rest explains many remarkable cases which would other-
wise seem at first sight at variance with antiseptic principles.
The following case, showing the contrast between blood clot
when kept at rest and when disturbed, is worth narrating.^
' On September 15, 1870, a young officer whose left upper
arm had been broken about its middle by a Chassepot bullet at
Noisseville seventeen days previously, arrived with an ambu-
lance train at the Tempelhof military hospital.
' The plaster of Paris apparatus, which had been applied at
once on the battle-field, had become soft and broken, and as the
patient complained of pain in the arm, probably as the result of
the journey, and as it was somewhat swollen, the apparatus was
removed, and a careful examination was made of the wound.
When I passed my finger into the wound after removal of the
crust, I felt numerous fragments of bone, but was, however,
astonished to find no trace of pus, only coagulated blood.
' After I had removed all the fragments, a plaster apparatus
with a window in it was applied ; nevertheless, there now resulted
a violent inflainination and suppuration of the wound, which
for a time threatened the young man's life.'
These views sufficiently reconcile the fact of union by first
intention in cases not treated aseptically with the germ theory
of putrefaction.
Now in order to have tissues in the state in which they are
capable of resisting the development of bacteria in their imme-
diate vicinity, they must be as much as possible in a condition
' Esmarch, Lanp:cnbcck's Arrliiv, vol. xx., p. lOr*.
286 ANTISEPTIC SURGERY.
of perfect health. To attain this, the health of the patient
must be attended to and kept good, and all causes which irritate
and cause the wounded part to inflame or become weaker must
be avoided. The causes which weaken the part are various
forms of unrest, mechanical or chemical.
To carry out this principle two things are required, viz.,
accurate approximation of the cut surfaces, and absolute immo-
bilisation of the part. Where accurate approximation of the
cut surfaces cannot be obtained, the same principle of absolute
rest must be carried out as regards the clot filling up the gap,
and it may thus resist the development of bacteria in its sub-
stance. Were T compelled to treat any case on this principle
alone, I should combine with it the open method, leaving the
wound freely exposed to the air. The superficial layer of the
clot, by drying up, would thus to some extent form an obstacle
to the entrance of organisms.
I have mentioned this as an antiseptic method, as the
principle is of great importance in explaining certain otherwise
puzzling cases, but I should not recommend it for adoption, for
it is only in a few cases, such as in face wounds, where the
vitality of the part is high, that this vital action of the tissues
and blood clot can be sufficiently trusted.
Such are the chief principles on which antiseptic surgery
can be carried out. In the class of antiseptic methods to which
I have referred in this chapter, the surgeon does not adhere
strictly to one or other principle, partly because the principles
on which he acts have not as yet been properly understood or-
appreciated, and partly beca\ise better results can be obtained
by their combination.
In many minor ways the antiseptic principle may be aided.
Thus, by the use of catgut ligatures, we do not have a long
septic thread hanging out of the wound, conducting putrefac-
tion into its interior and leading to deep-seated suppurations,
&c.
The silver suture acts in the same way as compared with the
silk. Silver does not absorb the putrescible materials, and thus
putrefaction does not occur in it. On the contrary, silk absorbs
blood and serum, which putrefy in it, and the silk which was
COXCLUSIOXS. 287
at first unirritating, becomes very acrid and causes inflamma-
tion in its vicinity.
What are the various means by which the general health
and tone are kept up in septic cases, what is the careful
selection of healthy individuals for operation, but imperfect
attempts at antiseptic surgery ?
What is ventilation but an antiseptic means ? The air being
constantly changed, the foul emanations from wounds contain-
ing septic bacteria are diluted and swept away, while at the
same time a better state of health is obtained.
And so I might go on enumerating various minute points
which have been, in ignorance of theu' true significance, adopted
in the treatment of wounds, all of which, more or less, act on
and promote antiseptic principles.
We thus come to the end of our discussion of the Principles
and Practice of Antiseptic Surgery. We have seen that anti-
septic surgery is simply a struggle with the causes of putrefac-
tion. I have not mentioned the germ theory of infective
disease at all. That has no essential bearing on the principles
of antiseptic surgery. All that is required of antiseptic
surgery is to prevent the occmTence of all kinds of fermenta-
tion. The germ theory of infective disease is, I say, an inde-
pendent view, and not part of those principles at all. It is
from mixing up these two theories that the confusion, and
much of the difficulty in accepting the principles of antiseptic
surgery, have arisen. Thus, for instance, a surgeon who writes
a good deal on this subject, after admitting to the full the genn
theory of putrefaction, states that he refuses to accept the
principles of antiseptic surgery and aseptic surgery in its train !
Speaking of the principles of antiseptic surgery, he says :
' Granting that the same germs which would inevitably produce
putrefaction in a dead infusion of beef are constantly admitted
to wounds, there is not the slightest particle of evidence that
they do produce any change whatever upon Uviiifj tissues, still
less is there any evidence that the changes which occur in the
numerous varieties of what we call blood poisonings, even when
they are of an undoul)ted]y hjcal origin, have the slightest
analogy to those seen in a putrefying dead infusion.'
Such a passage simply shows that the author is confusing
288 ANTISEPTIC SURGERY.
together the two germ theories —that of putrefaction with
that of infective disease. But, as I have already pointed out,
the germ theory of puti^ef action is the only vieiu at the basis
of antiseptic surgery ; and the author admits the truth of
this theory, and yet rejects aseptic surgery !
But let the germ theory of putrefaction be once admitted,
antiseptic surgery and, where possible, aseptic siu-gery, is
the logical, practical outcome. What does it matter for the
principles of antiseptic surgery what the precise relations are
which fermentations in wounds bear to the bad symptoms after
wounds ? These are points to discuss in connection with the
results obtained, but they are not the essential points to be
considered in determining the adoption or rejection of anti-
septic methods.
Leaving out of view the question of infective disease, and
supposing that we deny its connection with fermentations in
wounds, I would ask any surgeon who takes the above line of
argument, whether he would view with satisfaction the en-
trance of causes of putrefaction into the peritoneal cavity ?
I venture to say that he would not, and that the following
would be the result of his calmer cogitations : ' I do not
care at all what relations fermentations in wounds bear to
infective diseases, but I would rather not have putrefaction
present in the abdominal cavity, and I must insist on your
taking all possible precautions to prevent the entrance of its
causes. In other w^ords, I believe in the germ theory of putre-
faction, and I wish the methods of practice which follow
logically from such belief to be fully earned out in this case ; i.e.
I wish the strictest aseptic precautions to be employed. If, at
the same time, infective disease is also avoided, I shall be very
pleased, but I do not understand the causes of it. I do under-
stand, however, the causes of putrefaction, and I wish no pre-
caution to be spared by which it may be avoided.'
I venture to think that, with the mass of evidence now
existing, there will be very few disbelievers in the germ theory
of putrefaction ; and, as soon as a man accepts that view, he is
bound, as a rational man, to put his belief into practice on one
or other of the lines indicated here. He must do that, I say,
whether he believes in the germ theory of infective disease or
CONCLUSIONS. 289
not, were he indeed ignorant of the existence of such a view ;
though no doubt the precise amount of energy which he will
bring to bear in carrying out one or other method will to a
certain extent depend on the view which he takes of the
dangers which may arise from fermentations in wounds, and
these we shall have to consider when we come to speak of the
results of the various methods.
200 HISTORY OF ANTISEPTIC SURGERY.
CHAPTER XIV.
HISTORY OF ANTISEPTIC SURGERY.
Practice of the ancient writers. Attempts of tlie ancients to secure immedi-
ate union of wounds. Pare and Paracelsus: Delacroix: Arceeus: Progress
of wound treatment in the sixteenth century. Seventeenth century :
Magatus : Wiseman : Colbatch : Progress in the seventeenth century.
Eighteenth century and the early part of the nineteenth : Boerhaave : Col
de Villars : Heister : Bilguer : Benjamin Bell : Abernethy : John Hunter's
objections to the views of Bell and Abernethy : John Bell : opinions and
practice of other surgeons : Conclusions : Von Kern.
Antiseptic surgery being, as we have seen, a very wide
term, in endeavouring to take a philosophical view of its his-
tory and development, we must trace the development of the
methods of wound treatment during the last two centuries at
least. In doing so, and in order to avoid repetition when we
come to consider the results of the various methods, I shall
introduce into this historical part such details of the results
obtained as seem to me advisable.
Without entering into details on the practice of the ancient
writers, we may look on their modes of treatment as more or
less directed to making the wound heal. Thus, substances were
applied to Tnake the flesh grow, others to make the growing
flesh firm, and others to make the wound cicatrise. Amid all
these attempts, the tendency of the ivound itself toivards
healing was almost entirely lost sight of. It was supposed
that without these applications all sorts of evil results
would take place, and healing would not occur. These ideas
reigned paramount for centuries ; and we find them still ad-
vocated, not perhaps in such a glaring manner, up till very
recent times.
Nevertheless, there were surgeons who from time to time
were bold enough or had insight enough to protest against
EARLY WRITEBS. 291
these views. Amongst these we may mention Paul D'EdiNETA,'
who lived probably in the seventh century. . He proscribes the
numerous plasters, by means of which, he says, the action of
nature is choked, and he shows himself not ignorant that it
is to nature herself that one must attribute the successive
changes that wounds present. Eogerius,- in the thirteenth
century, also protested against the numerous dressings then
, in vogue, and used only wine and honey as local applications.
The rule at that time was not to attempt to close the
wound, even where that was possible, for it was supposed that
all sorts of evil humours would be pent up, and cause constitu-
tional affections. On the contrary, wounds were distended
with tents and plugs, which were covered with all manner of
ointments, and imbued with various kinds of medicaments-
Attempts were, however, made from time to time to procure
union. Among those who made these attempts may be men-
tioned Bruno,^ in the thirteenth century, who treated wounds
differently according as they were simple incised wounds, or
wounds with loss of substance. The former he closed at once,
while the latter were made to suppurate, except in cases where
nerves were injured, where he thought that 'putrefaction might
cause spasm : ' already we see the germ of the idea, which is at
present gaining ground, that there is an intim.ate relation
between tetanus and septic changes in wounds. Similar views
were expressed about the same time by Lanfranc,'* who wrote
at length against the dangers of tents, and who states that the
immediate union of wounds ought to be the first aim of the
surgeon in all cases of simple wounds, except in the case of a
bite by a mad dog.
During the next two centuries, sm-geons seem to have for-
gotten, or not to have paid attention to, the teachings of Bnmo
and I^anfranc, and to have still continued the practice of
endeavouring to remove morbid humours, and of altering the
supposed poisonous state of the surface of tlie wound by
numerous and varied applications. The most prominent surgeon
of tliis time was GuY DE CuAruAf",'' the celelM-atcd surgeon
' Soo I'Mrlal'-s JliMnlrc dc V Aiuiloiinc d dc In ('Iiiriirriif, 1770.
^ Ihifi. ■> IhUl.i. 17S. < ////>/. i.l!):5.
•^ CMrvrfjifi Mai/ua, rct^tituta a L. Joulicrto, 1585.
r 2
292 HISTORY OF AXriSEFTIC SURGERY.
of Moutpellier. He used no less than five different ointments
in the treatment of a simple wound.
At the end of the fifteenth century, or the beginning of the
sixteenth century, a new writer appeared in the person of De
Vigo,' who for a time exercised a great influence on the progress
of sm'gery. It was he who elaborated the dogma that gun-
shot wounds are poisonous, and that they must be burnt. He
speaks of the contact of the air with wounds as being very
hurtful, and for that reason he unites the edges early, taking
care not to leave any blood clots between the cut surfaces. He
also objects to the unnecessary use of tents, and only introduces
into the wounds lint covered with a digestive made with tur-
pentine. To the wound itself he applied various powders, some
of them containing antiseptic substances, and these no doubt
assisted to form an antiseptic crust.
In 1542 Michel Ais^ge Blondus^ wrote on the treatment of
wounds by water. After arresting hsemorrhage, and removing
foreign bodies, he applied dressings soaked in water.
From this period we begin the real history of modern
wound treatment. The two men who were most influential in
rescuing this department of surgery from the state into which
it had fallen, and in laying the foundation for the more modern
methods of treatment, were Paracelsus and Pare.
Philippe-Aureole-Theopheaste-Paeacelse-Bombast 3 was
bom in 1493 at Einsiedeln, near Ziirich, and spent the early
part of his life at Basle, as teacher of surgery. In his method
of treating wounds, he only aimed at aiding nature. He sup-
poses that there is a juice, distributed throughout the body^
which keeps the various tissues of the body in good health, and
repairs them when they are injured. The whole aim of the
surgeon ought to be to prevent alterations in this liquid, result-
ing either from its contact with air or from other accidents.
Nature alone is sufficient for this, as is seen in wounds of the
lower animals, and the essential thing is not to interfere with
natm-e. Medicaments are only of use as preserving this juice,
and preventing its corruption (puti'efaction). In the treatment
' The Must Ea'cellent Warlics of Chirvrgcryc, ifcc, ]54r,
- Portal's Histoire, i. 381.
^ Opei'a Medica Chimica, sire Paradoxa, 1603-5.
PARE. 293
of wounds he employed silver wire sutures, and bathed or in-
jected the wound with a solution of acetate of lead.
These views were adopted by Ambroise Pare (1509-1584 ?).'
He says: — ' Le chirurgien, pour la curation des playes, se doit
proposer une commune indication, qui est, union des parties
divisees ' . . . ' Or ceste premiere et generale indication est
parfaite par nature comme le principal agent, et par le chirurgien
comme ministre de nature ; et si nature n'est forte, le chirurgien
ne pourra venir a sa fin pretendue.' Pare mentions a variety of
topical applications, but his great aim is to keep the part at
rest. ' Preserve the temper of a wound by low diet, a little
wine, and rest ; avoid venery, contentions, brawls, angers and
other perturbations of the mind.' As is well known, he was
the first to show that gunshot wounds were not poisonous.
He simply enlarged these, and extracted any foreign bodies, and
then applied suppurative medicines. He regarded wounds of
joints as very fatal, and for the most part deadly, and here he
counsels the application of Venice turpentine, and not of sup-
purative medicines. His views with regard to air are interest-
ing. He looked on pure air as rather beneficial to the wound,
and to the patient, but the air of sick rooms, camps, &c., is
generally, as he supposed, loaded with miasms, and therefore
very dangerous, and it is the miasms in the air rather than the
air itself, which are the source of the danger.
It was chiefly by the writings and teachings of these two
men, that the ideas that the wound must be fed, that bad
humours must be removed, and that wounds cannot heal
without constant meddling, gave place to the true view that
natui'e is the only agent in the healing of wounds, and that all
that we can or ought to do is to remove anything which inter-
feres with its proper action. Pare looked more especially to the
constitution. He strengthened the body as a whole, while
removing, as far as he knew, any local disturbing causes. The
former is, however, the point which he considered the most
important.
Jean Andr^ Delacroix (1573)^ was one of the most suc-
' QHuvres Completes, par J. F. 31'algaigne, 18-10. See also The M'orhs of
that f anions Chiru/rgion, translated by Thomas Jolinston, 1GG5.
"^ Portal's Ilistoire, ii. 41.
L>n4 HISTORY OF AXTISErTIC SURGERY.
cessful surgeons of that time, and adopted the views just related
as to the powers of nature. He used antiseptic substances very
largely. Thus he recommends strongly, as applications to
wounds, ethereal oils and substances containing alcohol. After
the bleeding had been arrested and foreign bodies removed,
he washed out the wounds with some ' detergent liquid,' and
then applied plasters containing chiefly pitch and oil of tur-
pentine. His results were exceptionally good.
The bad effects of the air were much feared by WiJRTZ,' who,
in order to prevent its access to wounds, kept the doors of the
sick room closely shut while he rapidly changed his dressings.
Fallopius ^ also, about the same time, from the same fear
of the air, made a number of experiments on healing under a
crust.
The method of treatment employed by P'RANgois Arc^US ^
(1574) was more simple than any of the others used up to that
time. Having arrested bleeding, and removed foreign bodies,
he washed the wound with alcohol, or with wine containing
myrrh or other similar substances, and brought the edges to-
gether with sutures, leaving an opening which could be kept
open, if necessary, by a piece of lint introduced into it. He
then applied a balsam, which afterwards attained great celebrity,
and which he describes as follows : — ' Prenez terebenthine claire
et baume elemi une once et demie de chacun ; de la graisse d'un
animal cliatre, deux onces ; vieille graisse de pore, une once.
Faites foudre tons ces ingrediens a un feu modere, et vous
aurez un liniment que vous ferez foudre toutes les fois que vous
voudrez vous en servir. Vous en oindrez la plaie avec une plume
et vous couvrirez le tout avec un emplatre de Vigo.' He had
some remarkable results by the use of this method, which really
is a fair antiseptic method, and not far removed from an aseptic
one.
ViCARY,'' towards the end of the same century, washed out
wounds with a balsamic water, stitched them up, and covered
' Practica cler Wuinlarztncij, Basel, lo'.tO.
- Opera Omnia, 1600-6.
3 A 'most JExcellcibt and Covijjcudious Mcthud of ciiriini W'oundcs in the Head
and ill other Parts of the Body, translated by John Head, 1588.
■' Tlie A'lir/Hshman's Treasure, <^'c., 1G2G.
^SEVENTEENTH CENTUIiY. 295
them with various balsams, and he speaks of the excellent
results which he obtained in this way.
The great advance in this century was the reassertion of the
part played by nature, and the abandonment of the ideas of
feeding wounds or of making flesh. Here also we have the
first strong recommendation to apply antiseptics to wounds,
and the success of these applications, in the hands of Arcseus
more especially, is vouched for by the fame which his balsam
afterwards acquired. Nevertheless, as such methods were
simply the result of chance, and did not arise from any glimpse
of the true principles which were at work in obtaining the good
results, they never became established modes of treatment.
During this century, two writers more especially, Paracelsus and
Wiirtz, looked on the admission of air to wounds as a very bad
thing, while Pare went the length of ascribing the harm not
so much to the air as to miasms contained in it.
Seventeenth Century.
The evil effects of air were, however, most prominently
brought forward by Magatus * (1516), to whom also must be
accorded the credit of having first thoroughly recognised the
importance of rest in the treatment of wounds. He says that
the air is charged with miasms, which infect the parts with
which they come in contact. He points out as an instance of
this, the rapid putrefaction of an egg if a hole is made into it.
He also writes strongly in favour of perfect mechanical rest,
for he thinks that movement is a frequent cause of the bad
results which follow wounds. With the view of obtaining both
objects, the exclusion of air and perfect rest, he recommends
very infrequent changing of the dressings ; indeed, he only
changed them when it became absolutely necessary. He left
spaces between the sutures for the escape of pus, but he
objected strongly to the use of tents. He did not wipe away
the pus from a wound, because he thought that it ultimately
formed the cicatrix, and in the meantime protected the wound.
These infrequent dressings, owing to fear of bad effects from
the contact of air with the wound, were, as we now know, the
outcome of a wrong theory ; and although Magatus's teaching
exercised great influence down to recent times, yet in the case
' De rata Midlcatiunc r«^«t'/(t/«, IGIG.
L>9G HIISTORY OF ANTISEPTIC StfRGERY.
of those who have studied and acted on his views, the reaction
has been so great when they have discovered how insufficient
they were, that the good points in his method were for a long
time Hkewise rejected.
During this seventeenth century, there was but Httle pro-
gress made. The accumulation of dressings, which had been
given up to some extent at the commencement of the century,
had been again introduced, chiefly as the result of Magatus's
teaching on the bad effects of air. These dressings contained,
however, balsams and other antiseptics of various kinds, and
thus the bad effects which must have arisen from keeping
putrid dressings in contact with wounds for a long time, may
have been to some extent avoided.
It is interesting to note, in reference to our future considera-
tion of the results of various methods of wound treatment, that
Magatus's method by no means did away with the dangers of
such injuries as incisions into joints. Thus, to quote from
James Cooke's ' Marrow of Chirurgery ' (1685) ; under ' Wounds
of Joints,' he says : ' If a wound associate to a dislocation so
that the joynt be bar'd and a little thrust out of the skin ; in
great joynts 'tis deadly, in all bad : yea, after set, there oft
follows inflammation, convulsion, &c., especially if withal there
be a fracture near the joynt.'
That advance was being made, and that the teachings of
Mao'atus were not blindly followed, is evident, for example, from
the writings of Eichaed Wiseman • (1692). Wiseman's views
on the healing of wounds and his methods of treatment were re-
markably good. In uniting the edges of a wound, he says that
one must not force a pledget of lint between the lips, nor use
violence. Unite the parts gently and equally ; then ' preserve
the natural temperament of the part, that thereby agglutina-
tion may be obtained.' Agglutination is the work of nature
alone. Blood is the natural glue, and hence great care must be
taken that it is good. Attend therefore to diet and regimen.
Support the patient's strength. Do not stop strong drinks, if
the patient has been accustomed to them. Do not purge ; but,
if necessary, give gentle laxatives. He used as applications to
wounds such remedies as turpentine, and outside this he applied
1 Chirurgical Treatises, 1G92.
Sm JOHN COLBATCIL 297
cooling and astringent lotions. Powders of various kinds were
sprinkled over the larger wounds.
At the end of the seventeenth century appeared a most re-
markable series of treatises by Sir John Colbatch,' in which he
describes results obtained by the use of a medicament, which
he unfortunately does not mention, but which gave him results
only comparable to the true aseptic results obtained at the
present day by the use of the aseptic method. That he
should have concealed the name of the substance employed
cannot be too much regretted ; but that nevertheless he was no
ignorant quack, telling falsehoods simply to sell his wares, is
shown by the position which he ultimately attained in his pro-
fession. The accuracy of his results are also attested partly by
the publicity with which they v/ere obtained, but chiefly by the
clearness of the description which he gives of the progress of
his cases — a progress which could not at that time have been
imagined by any one who had not seen the facts. A typical
aseptic course is described, while there is no doubt that he had
observed vascularisation of the blood clot, and its replacement
by new tissue, just as has been described in the present day by
Mr. Lister.
In his preface he asserts ' that the method of chirm'gery
hitherto used is not the best ; that all probes and tents, all
digestive and suppurating medicines, all cauterizing and straight
ligatures are injurious to the patients, and procrastinate their
cure.' His view is, that when a wound is made the ' nutritious
juice ' escapes from the vessels. ' Now all the medicines used
in the common methods of chirurgery are of such a nature as
to relax the divided fibres so much, that they cannot contain
the nutritious matter brought to them, but let it pass into the
wound, where it is by the same medicines corrupted and turned
into that substance we commonly call matter. Now the corrup-
tion of the nutritious juice cannot be performed without a sort
oi fermentation, and it is the fermenting particles that, fretting
the fibres, cause inflammation in wounds, and by entering into
the blood, and dividing its texture, cause symptomatic fevers,
which frequently prove so fatal.' He then goes on to say that
by the medicines in common use surgeons cause suppuration
' Nonnn Lumen chirimjicum, &c., by Sir Julin Colbatcb, 1704.
298 HISTORY OF ANTISEPTIC SURGERY.
and often mortiticcition, ' and when nature is almost tired and
oppressed, weak as she is, they leave her to do her own work.'
In the cases where the cavities of the body are wounded, the
patient is considered certain to die ; ' for to bring a wound in
the lungs, liver, guts, &c., to suppuration is to bring certain
death, and to cure a wound without bringing it to suppuration,
they don't pretend.' He then refers to the fact that in all
wounds the patients were put on low diet, and more often than
not blood was taken in large quantities, ' to the great weaken-
ing of their patients.'
As to Colbatch's method. ' Suppose a wound be made with
a sword, or other cutting instrument, the length or depth of
W'hich signifies nothing, I make a solution of my Potvder in
water, for want of which, in urin ; and as soon as conveniently
I can — the sooner the better — I either squeeze, or with a syringe,
if the wound be deep, inject into the wound some of the said
solution ; I then close the lips of the wound together, which, if
wide and large, I stitch up. When I have so done, I apply a
pledget of fine tow, wet in the said solution, to the wound ;
not letting it go into it, but only to cover the edges of it, and
lie all over it. And if there chances to be any large artery cut,
I hold on the pledget close with my hand till the flux of blood
ceases, which will be in a small time, otherwise not ' (he speaks
of his medicine as a hsemostatic) ; ' afterwards I bind it on with
a very easy ligature, then I give my tincture in wine.' In
incised wounds one dressing, or at most two, were as many
as were requisite, the second being applied at the end of three
or four days. In wounds with loss of substance more dressings
were necessary, and these were changed once in four days.
As to his results, he says : —
' First of all, my medicines never cause any pain, unless it
be just when the external one is squeezed or injected into the
wound, and that pain is little more than what would be caused
by using spring water in the same manner.
' Secondly, there is no pain afterwards, but the parts are
pliant and easy, as if not hurt at all.
'Thirdly, if there has bin great pain before, according as
it has bin greater or less, so it has bin longer or shorter
before taken off, but the greatest in a short time. As when a
,SlIi JOHN COLBATCH. i>99
wound had bin long received, and bad other applications to it
before mine, had bin much inflam'd and the parts adjacent
much swell'd, and consequently the party in great pain, all
these symptoms have bin totally taken off in twenty-four or
forty-eight hom's at furthest and many times in such cases the
greatest pain taken off in a few minutes. But they have never
bin the cause of pain, swelling, or inflammation, which, by the
way, is a certain argument they are no caustics, as some mali-
ciously and falsely report.
' Fourthly, there has never any such thing as a fever, let the
wound be ioterual or external, attended any who have used my
medicine soon after they have bin wounded ; but several who
have bin ill-managed before, and thrown into violent fevers,
have in twenty-four hours, by the use of my medicines, bin
totally freed from them, and that without blood-letting or ab-
staining from flesh or wine, the more of which they drink, so
they keep within bounds, I always find them the better.
' Fifthly, in all incised wounds, where my medicines have
bin soon enough used, and no other applications preceded,
they are perfectly cured in a few days without suppuration, and
I have frequently observed that at about four days' end, such
wounds have bin filled with a substance much like hartshorn
jelly, which I have conjectured to be young flesh, and in two or
three days I have found my conjectures true, the said substance
being converted into good flesh. But where wounds have bin
long receiv'd and matter generated, they have bin cured in a
small time, without repeating the application above once in
three or four days. I have had to do with wounds long re-
ceived, which have bin both deep and large, and by the
common methods must have discharged a great quantity of
matter, but the quantity of matter coming away after using the
medicines, has bin so small, that I have good reason to con-
jecture it was no more than what was formed before they were
applied.'
These statements correspond very much with what are now
made by the supporters of the aseptic method, and they could
hardly, more especially where he seems to describe organisation
of blood clot, have been imagined at that time. Supposing
that this powder were an antiseptic, the method employed is
300 HISTOllY OF ANTISEPTIC SURGERY.
practically the same as that which I have described when no
spray is at hand : fill the wound with the antiseptic lotion ;
stitch up and apply your antiseptic dressing. Neudorfer, who
also mentions Colbatch, thinks that this powder was a salicylate ;
probably, on account of the smell of roses to which Colbatch
refers, salicylate of ammonia.
Thus in the seventeenth century but little real progress was
made. The great aim was to exclude the air, and to avoid
mechanical causes of unrest ; the chemical causes of unrest
were not at all understood. Colbatch's method seems to have
been completely lost, no doubt on account of his concealment
of the natm-e of the substance used.
Eighteenth Century and the Commencement of the Nineteenth.
AuGUSTiN Belloste' (1700) reiterates Magatus's teaching.
He fears the contact of the air, chiefly on account of the
miasms which it contains, and in order to exclude these, and
also in order to obtain mechanical rest, he recommends in-
frequent dressings. He fills his wounds with charpie and
follows Magatus in not washing away the pus. He advocates
immediate union in cases where bones are divided. ' L'expe-
rience m'a fait voir,' says he, ' en mille occasions que quand un
OS est simplement decouvert, tout consiste, pour en eviter
I'alteration, a le defendre des attaques de I'air. Pour cet effet,
il faut procurer la reunion de la plaie le plus tot qu'il sera
possible, par le moyen des bandages propres et des remedes
balsamiques, sans la dilater avec les tentes et les bourdonnets ;
par la I'os se recouvre promptement, et on evite I'exfoliation,
qui est absolument necessaire quand on a donne le temps a I'air
d'y faire ses impressions.'
In 1706 Parmanus^ speaks of a lotion which he uses for
wounds, which ' resists putrefaction, prevents ill accidents, and
takes away the inflammation and pain of the wound.' His
dressings were kept constantly moist with this lotion, and
changed once in two or three days.
In the same year Anel ^ published an account of a method of
' Le cJiirvrgieii d'Hopttal, 1707. * Chirvrgia Curiosa, 1706.
^ Portal's Ilistaire, iv. 398.
EIGHTEENTH CENTURY. 301
evacuating abscesses by aspiration, without leaving an open
wound. A similar kind of instrument for the puq^ose of re-
moving blood from the thorax had been previously described by
Delacroix (1573).
As we have seen, the dread which surgeons as a rule up, to
this time entertained of admitting air to wounds was not so
much because it caused putrefaction of the discharges of
wounds, but because it contained miasms which were hurtful
to the patient. The connection between internal abscesses and
wounds had been hardly as yet observed, and it was not till
Boerhaave wrote, that this connection was recognised, and that
a 'putrid discharge in a wound became a thing to be avoided.^
Boerhaave 2 (1720) pointed out the frequency of internal
abscesses after certain injuries, and he ascribed this to the ab-
soq^tion of pus by the open orifices of the veins of the wound.
Boerhaave went further, and ascribed the evil effects to the
putridity of the pus. This is very evident in the following
quotations, which Jeannel (Pyohemie) gives from Boerhaave's
aphorisms : ' Si turn relinquitur (pus) diii in loco clauso, attenu-
atur, acre fit, putrescit, augetur, vicina consumit, erodit, mole,
pondere et motu sinus fistula sque creat variis locis, varias,
pessimas in intestino recto ; ' and also, ' Aut dissipata parte
tenuiori reliquum durescens tumores duros, maxime circa glan-
dulos creat, vel denique (pus) venis lymphaticis aut sangui-
feris, per eroso osculo impressum absorbetur,' &c. Jeannel also
quotes passages from Pare to show that he attributed the fever
which accompanied wounds to a putrefaction of the jjus.
Boerhaave's views were adopted by Le Dkan^ and Heister;
and, in 1741, we find the necessity of frequent dressings, in
order to prevent putrefaction, strongly urged by Col de
Villars.'' The latter author advises that if there be much
suppuration, the dressing should be changed twice a day. He
' Tliat wounds of the skull were apt to l)e followed by abscesses in the
liver was long before noticed by Pare and others, but the significance of the
fact was not understood.
- Ajikorixvis concerning flw Kvoirlcdfjc (ind Citrc of iJ'ntcaKc, Xnin&hxXcxX by
Delacoste, 1715.
* Billroth, Ilistorische Stndicu iibcr die Bcvrthdluiifjen dcr Schusm-undcn
1859
•• f'ofirs dc ChirHnjie, ii. 17-41.
302 HISTORY OF ANTISEPTIC SURGERY.
employed compresses soaked in wine or in Imlsams, sucli as
the balsam of Arcaeus, or covered with an ointment consisting
of equal parts of wax, turpentine, and oil of hypericum. In
order to avoid the contact of the air the dressing was changed
as, quickly as possible.
Heister' (1753) used balsams very extensively, not because
he held that they conduced to form new flesh, but chiefly be-
cause they removed everything that might hinder that pro-
cess, more especially putrefaction. In order to prevent the
access of air, which he considered hurtful, ih.& surgeon was in-
structed not to remove the old dressings till the new were ready
for application. Heister attended to the drainage of his wounds,
and, if necessary, he made a counter-opening into which he
introduced a piece of lint covered with some sort of balsam.
The edges of the wound were brought together either by stitches
or by plasters composed of various balsams.
The most important work, however, in which the action of
antiseptics is especially recommended, was Bilguer's^ (1764).
His method of treatment in all kinds of wounds consisted
essentially in filling all the recesses of the wound with antisep-
tics, and laying over the wound a piece of lint dipped in an
antiseptic solution. His method is specially described in con-
nection with cases of mortification. He makes incisions through
the dead parts, which incisions should be large and numerous,
but should not touch the living part. He then squeezes out
the corrupted humours, and pom's in the following mixture : ' Of
frankincense, mastick, sarcocolla, and myrrh finely powdered,
true balsam of Peru, and genuine essential oil of cloves —
equal parts ; of balsam of Fioraventi, as much as may, after
mixing all the ingredients over a very gentle fire, form a thin
liniment.' Over this is laid some dry lint, thoroughly sprinkled
with a powder composed of ' an ounce of myrrh finely powdered,
half an ounce of sal-ammoniac, camphor and nitre — of each a
drachm.' If necessary, fomentations may be applied outside this.
These fomentations should be com2:)Osed of 'a pint of lime-
water, 3 ounces of camphorated spirits of wine, and H ounce
' Clcnvral Sjixicvi of Sin-f/tTi/, translalcd 1753.
- A DiHStoiation on the Invtllif)/ of fhr Atnjmfofiitn of the Linilm, witli
notes by M. Tissot, 1764.
BILGUER. 303
of sal-ammoniac' A variety of other mixtures and methods of
treatment are mentioned, but the quotations will show the
essential points.
In this method the thorough application of these sub-
stances would no doubt result in complete asepticism ; and the
results which he obtained are very remarkable. From his ex-
perience, he sets his face strongly against amputation. He
says : ' The cutting off a limb being the severest means
employed in surgery for the relief of mankind — an operation
which every one beholds with horror — I cannot, I imagine,
better accomplish my design, or do a greater service than by
demonstrating that the cases wherein amputation is necessary
are much less frequent than has been hitherto supposed, and
that it may even be almost totally dispensed with.'
With regard to his results he says : ' I have had under my
care, during the course of the late bloody war, a great number
of wounded limbs, torn and shattered by cannon and musket-
balls, by the bursting of bomb-shells and grenades, by grape-
shot, &c. I cured them without ever performing amputation
. . . although there were bones broken and shattered, large
blood-vessels divided, the flesh miserably lacerated, and limbs
carried off; others in which the bones were split up as high as
the articulation ; all which circumstances might make us rea-
sonably apprehend a tedious and difficult cure, too plentiful a
suppuration, haemorrhages, violent inflammation, excessive cor-
ruption, mortification, and death.' . . .
' I had at one time, during the war, in a military hospital,
6618 wounded persons, who were all treated according to my
direction, and part of whom I attended myself. Of these, 5557
persons were perfectly cured, and in a condition to support all
the fatigues of the service; 195 were able to do duty in garri-
son— what they call " half-invalids " — or to work at any trade ;
213 remained incapable of any labour, civil or military, what
they call "grand invalids," and 653 died.'
The 195 and 213 invalids belonged to the class of cases
who had their bones bruised, broken, or sliattered. After a
calculation which I need not go into, he very reasonably con-
cludes that ' much the greater part of these 408 men cured
and sent to the Invalidcs would have died if amputation had
,'J04 HISTORY OF ANTISEPTIC SURGERY.
been performed.' He compares this with the ' prodigious
numlier of wounded men who at the beginning of the war had
their limbs taken off on account of dangerous wounds, of whom
scarce one or two escaped with their lives.' He concludes
thus : ' Further, if it be considered that many of those who died
might have recovered, had they been taken care of anywhere
else than in an hospital, where the air is very bad, and if it be
called to mind at the same time, what some very eminent sur-
geons have observed, that two-thirds of those die who have
their limbs cut off, I hope it will be readily acknowledged
that my method of treating wounded limbs by saving them, is
highly preferable to that of amputation.'
As a contrast to this method I may refer to that used by
Percival Pott* (1768) in compound fractures. Wliere the
limb is treated conservatively, he recommends immediate reduc-
tion, and then he mentions two requisites: 1. The mainten-
ance of a proper opening for the free escape of discharges — a
counter-opening being made if necessary ; and 2. The preven-
tion of inflammations in order that the wound may heal, as far
as possible, by first intention. His dressing was a piece of dry
lint next the wound, and outside this a ' pledget spread with a
soft easy digestive.' As the result of this treatment in com-
pound fractures, wounds of joints, &c., he thinks that the
patient has the best chance by immediate amputation. Thus
Bilguer, by his piles of dressings, but these acting more or less
completely on aseptic principles, regards compound fracture as
a much more favourable accident than does Percival Pott with
his simple non-antiseptic dressings.
Towards the end of this century, the evil influences of air
on wounds was brought very prominently forwards, more espe-
cially in England. About this time Pkingle ^ published a work
on the diseases of the army, in which he speaks of diseases
arising in consequence of foul air, and narrates a series of ex-
periments made with various antiseptic substances.
In 1 784 Benjamin Bell ^ published his treatise on the theory
and management of ulcers, in which he speaks very strongly
' (,'hiriirgical WorTis, edited by Sir James Earle, 1808.
^ Ohscrrations on the Diseases of the Arvnj, tliird edition, 17(!1.
^ Treatise oti the Theory and ManoAiement of Uleers, 1784.
BENJAMIN BELL. 305
of the bad effects of air : ' The bad effects of air,' says he, ' on
every species of sore are well known to every practitioner, but
its pernicious influence on a newly opened abscess is often
really astonishing. It first occasions a total change in the
nature of the matter, from perhaps a very laudable pus to a
thin ill-digested sanies, and afterwards brings on a quickness of
piilse, debilitating sweats, and other symptoms of hectic fever,
which for the most part, when the collection has been con-
siderable, either carries the patient off in a short time, or ter-
minates in a confirmed phthisis, which sooner or later proves
fatal.' How air acts he does not know, but he thinks that it
may stimulate the absorbents to greater absorption of pus,
' and it may likewise, by rendering the matter more putrid than
before, give even to the same quantity greater activity in pro-
ducing the different symptoms of hectic' On this principle
(of preventing putridity) he would account for the operation of
many of the remedies commonly employed at that time in the
treatment of sores. As a means of avoiding all these dangers,
he recommends the introduction of a seton into an abscess,
and he thinks that the progress of cases so treated is better
than that of those in which the abscess is laid freely open. In
hydrocele, however, he found that the use of the seton was
followed by great pain and constitutional disturbance. From
what has gone before it will be readily understood why such
disturbance resulted, and also that, in the case of the abscess,
no real benefit was derived.
Benjamin Bell also used leaden drainage tubes. In incised
wounds, after bringing the edges together, he applies ' no
dressings except a thin covering of soft lint to protect the
parts beneath from cold, and to keep out the air.'
He is always reiterating the statement that ' nothing proves
more hurtful to sores than exposure to the air ; ' and he directs
his efforts to excluding the air by closely applied ointments, &c.
He also details the disastrous results of wounds of joints, and
he says that many authors advise innnediate amputation in
such cases. In small wounds, however, he draws down the
skin and stitches it in such a position as to make a valvular
opening.
He proposes a valvular incision for the removal of cartilages
X
306 HISTORY OF ANTISEPTIC SURGERY.
from joints where the cartilages are quite loose, but where they
are attached to any part of the synovial membrane, and the
jiain is insupportable, he would advise amputation as ' less pain-
ful as well as less hazardous.'
Similar views as to the bad effects of air on wounds were
expressed by Hugh Munro ' (1792) ; and he agrees with Bell in
attributing the disastrous consequences following wounds of
joints and incisions into psoas abscesses to the entrance of air
and the putrefaction of the discharge.
Alexander Munro '^ (1788) had previously written on the
bad effects of air on serous sacs, but he thinks the coldness of
the air is their chief cause.
James Latta^ (1795) gives the teaching of the Edinburgh
school, which is essentially that of Benjamin Bell. He says that
the admission of air into abscesses ' is immediately attended
with symptoms of putridity ; the pus, which at first was white,
thick and free from any foetor, becomes instantly thin, foetid,
and corrosive ; a quick pulse and hectic sweats come on, from
which the patient scarcely recovers, if the collection of matter
has been very large.'
In the Encyclopedie Methodique (1790) Alexander Munro's
idea as to the coldness of the air being the injurious factor is
upheld, but, at the same time, the impurity of the air is also
brought forward, and an attempt is made to prove its influence
by citing the different resvdts of am})utations in town and
country.
The advocate of the bad effects of air who succeeded
in turning his views to the best account was, however,
AbernethV* (1793). He first points out in his 'Essay on
Lumbar Abscesses ' that ' whilst the condensed cellular sub-
stance which forms the cyst of an abscess remains entire, it
continues free from inflammation, and the contained pus suffers
no putrefaction, nor evident alteration of quality ; . . . when-
ever the abscess is o])ened, either by ulceration or by the hand
of the surgeon, a sudden and generally considerable inflamma-
tion extends over the whole cyst. This is followed by a cojuous
' A Com])en<lioui^ Si/Klem oftlir Thcori/aiid I'racitccvf Mmlvrn Snrf/cry, 1792.
- Bwao' Miicosf/; 1788. ^ Practical System of Sim/cry, 1795.
* Svryical and Pliysiohyical Essays, 1793.
ABERNETHY. 307
discharge of frequently foetid pus.' Abernethy's writings are so
well known, and so well worthy of perusal, that it is unnecessary
for me to discuss them in detail. His principle of treatment
was to reduce the size of the cavity to as small dimensions as
possible by successive tappings of the abscess, and when this
was done, the remaining sac was opened. This method was
first carried out by drawing off the pus by means of a trocar
and canula, but that was soon abandoned for a valvular incision.
Several cases are recorded which clearly show the advantages of
the method.
In investigating the reason why air does harm, Abeniethy
discusses the views as to whether it is on account of some
irritating property which it possesses, or by causing putrefaction.
He concludes, from observation of the phenomena eeen in em-
physema, and also from Astley Cooper's experiments, in which
he inflated the abdomen with air without causing any harm,
that the first supposition cannot be correct. Nor does he
think that it is the putrid matter which does the harm, for ' if
the matter had only an incomplete discharge, if it was confined
in a state of putrefaction, and thus applied to the surface of
the abscess, it surely would be in some degree injurious, but
as the outlet in general is sufficient, and as the former matter
is washed away by that which is newly secreted, this is not
likely to be a common occurrence.' His belief is that it is
partly the primary injury to the cyst when it is opened, but
chiefly the constant action of the air. ' The circumstances,
however,' he says, ' are different ' (from those in Astley Cooper's
experiments). ' When the opening is permanent, a constant
renewal of air is permitted ; and the application of a matter so
unusual to these sm'faces, I am inclined to believe, does harm.'
In his ' Lectures on the Theory and Practice of Surgery '
( 1 830), he speaks of the objects to be aimed at in the treatment of
wounds, viz. position, accurate union, avoidance of movement
or tension, and prevention and mitigation of inflammation.
Stitches are bad, and he uses plasters instead. He approves of
leaving wounds open till they become glazed, and then, when
the edges are brought together, he covers them very lightly or
leaves them quite exposed.
The dangers of air, and the advantages of the valvular
808 HISTORY OF ANTISEPTIC SURGERY.
method, were accepted by the leading German writers of this
period.
JoHANN Christian Anton Theden ' (1795) used a lotion for
wounds, consisting essential!}' of sorrel water and alcohol. He
speaks of washing out wounds with warm wine, then bringing
the edges together, and applying compresses soaked and kept
moistened in this lotion. He does not regard wounds of joints
as so dangerous as other writers have made them out to be ; and
he mentions a case of compound fracture of the olecranon from
a sword cut, in which there was but little fever and discharge,
and the joint was ultimately only somewhat stiff. Three cases
of removal of loose cartilages from the knee-joint are narrated.
Pressure was made during the operation so as to prevent the
entrance of air, and then his lotion was applied. Two cases
did well, the third patient got a ' malignioses Fieber ' after the
operation, and died. Theden does not think that this bad
result was a consequence of the operation.
August G-ottlieb Eichter (1799)^ advocates the free re-
moval of pus by counter-openings if necessary. He used various
digestive ointments, and rather tended to the old style of stuffing
an open wound without employing any special antiseptic means.
It is interesting to note that with him the question of amputa-
tion in gunshot injuries and compound fractures is brought
prominently to the front. He fears an absorption of pus, if
attempts are made to save the limb, and this absorption is,
according to him, always followed by death. He advocates
Abernethy's method of opening lumbar and psoas abscesses.
These views as to the bad effects of air on wounds and in
abscess cavities were not allowed to pass unchallenged, 'and
were especially objected to by John Hunter and John Bell.
John Hunter (1792)^ ascribes the bad consequences follow-
ing a wound to the injury itself, and not to the action of the
air. A disposition in the part to inflammatory action may also
be superadded. In speaking of the view that air is a cause of
snpi)uration, he says ; ' Various have been the opinions on this
' Xene Bemerkungen unci ErfaUrwigai zur Bcrcichervng der Wumlarznei-
hinst, 171>5.
- Anfai)(is-grunde der WmidurziieiJnivKt, 17'.)9.
* John ilunfcr\i WorJis, Vol. III., edited by F. Palmer, 1835.
JOHN HUNTER. 309
subject ' (the question of inflammation in wounds) ; 'and as every
violence committed from without, under the circumstances
before mentioned, is exposed more or less to the surrounding
air, the application of this matter to internal surfaces has
generally been assigned as a cause of this inflammation ; but air
certainly has not the least efifect upon those parts, for a stimulus
would arise from a wound were it even contained in a vacuum.
Nor does the air get to the parts that form circumscribed
abscesses, so as to be a cause of their formation ; and yet they
as readily suppurate in consequence of inflammation as exposed
surfaces.
'Further, in many cases of emphysema, where the air is
diffused over the whole body, we have no such effect — and this
air not the purest — excepting there is produced an exposure or
imperfection of some internal surface for this air to make its
escape by, and then this part inflames. Nay, as a stronger
proof, and of the same kind with the former, that it is not the
admission of air which makes parts fall into inflammation, we
find that the cells in the soft parts of birds, and many of the
cells and canals of the bones of the same tribe of animals,
which communicate with the lung, and at all times have more
or less air in them, never inflame ; but if these cells are ex-
posed in an unnatural way, by being wounded, &c., then the
stimulus of imperfection is given, and the cells inflame, and
unite, if allowed ; but if prevented they then suppurate, granu-
late, &c.
' The same observation is applicable to a wound made into
the cavity of the abdomen of a fowl, for there the wound in-
flames and unites to the intestines to make it a perfect cavity
again ; but if this union is not allowed to take place, then more
or less of the abdomen will inflame and suppurate.
' If it was necessary that air should be admitted in order for
suppuration to take place, we should not readily account for
suppuration taking place in the nose from a cold, as that part
is not more under the influence of air at one time than at another ;
nor is the urethra in a gonorrhoea affected by the air more at that
time than at any other ; these parts being at all times under the
same circumstances with respect to air. Therefore, there must be
another cause.' Truly there is another cause, as has been
310 HISTORY OF ANTISEPTIC SURGERY.
already demonstrated, but not the one John Hunter supposed,
as we shall see when we consider the results of subcutaneous
injuries and subcutaneous operations.
John Hunter's treatment of wounds is very simple. He
wished to allow nature to perform her work herself, simply
applying poultices or ointments to allow the protecting dress-
ing to come off easily.
It is in his views on healing by scabbing that we are mainly
interested. He observed that when blood dried on a wound,
that wound often healed without suppuration ; and hence he
concluded that a scab was an obstacle to suppuration, chiefly
because it precludes the necessity for the formation of discharge
to act as a covering for the exjiosed surfaces. He considered
that it was the best practice to let superficial wounds scab
over. Many deep-seated wounds also, where the deep parts
are in contact, may be allowed to scab. This ought likewise
to be done in cases of compound fracture with a small external
wound. In large wounds this formation of a scab did not
always succeed, but he did not think that there was any danger
in trying to get it. In such cases the crust formation could
be aided by the sprinkling of powders over the surface, such as
chalk or lapis calaminaris. Where suppuration occurred under
the crust, he did not even then remove it in the first instance,
but pressed out the pus in the hope that the remainder might
dry up. When, however, it was evident that harm was being
done, he applied poultices and removed the crusts.
John Bell ' likewise denied that the bad results of wounds
were due to the admission of air. In the edition of his ' Prin-
ciples of Surgery,' edited in 1826 by Charles Bell, he opposes
strongly the idea that air can in any way cause inflammation,
and he criticises severely Munro's book on the ' Bursse Mucosae.'
He points out that in the case of abdominal wounds or of psoas
abscesses air cannot enter the cavity. He further adds : ' That
the air which we breathe, and which we feel upon the surface
so bland and delightful, should have so opposite a relation to
the internal parts, that it should there be a stimulus more
acrid and more dangerous than the m'ine or bile, is not to be
believed upon slight grounds : this misfortune of inflammation
Prinrijilex of Siirr/rry, edited by Sir Charles Bell, 1826.
JOEN BELL. 311
running so quickly round all the surfaces of shut sacs, where-
ever they happen to be wounded, proceeds altogether from
another source, simple and plain to the last degree. For, in
the wound of any shut cavity, where the parts do not adhere,
the inflammation spreads and runs its course by a law of the
animal economy, which we explain very ill when we call
adhesion, the adhesive stage of inflammation, rej)resenting, as
the first stage of a most dangerous disease, that adhesion which
is a natural and healthy action, the most natural in all the
system, and the farthest from disease. Thus, in a wound of the
breast or belly, in a joint, or in any shut sac, if the parts, being
neatly laid together, should once adhere, then there is no
swelling, no pain, no formation of matter, the parts are well
and sound in the very moment in which they adhere ; thus it
is sometimes in narrow or slanting wounds. But if the wound
be broad and open, or if the least thing keeps the lips apart
from each other, or if they run into inflammation, then the lips
tuna away from each other, matter forms, the wound inflames,
and not the wound only, but also the wounded cavity inflames,
so that if it be in a vital part, the man dies.'
In speaking of compound fractures and dislocations, after
citing the opinion of French surgeons, chiefly Palfin and
Duverney, that amputation should always be performed, he says :
' We do not comply with any such barbarous rule ; ... we know
that nature will do wonders, but they are wonders, and we
never enter upon the attempt of preserving a limb thus desjDer-
ately fractured without awful hesitation, and when we do venture
to dilate the wound, and push back the bones, or saw them
off, we feel all the responsibility of what we have just done.'
Of wounds of joints he similarly says :^ ' We here pronounce
the opinion which we have too often to deliver in common
practice, that openings into inflamed joints are fatal ; and though
there are in every book cases of anchylosed joints, we cannot
forget that for one that has escaped by anchylosis, thousands
have died.' Such are the results of his treatment, founded on
the views we have quoted.
He says, with regard to the methods of treatment : ' When a
modem surgeon allows himself to talk about the mundifying,
' Discourses an tJie Nature and Cure of Wounds, 1812.
312 HISTORY OF ANTISEPTIC SURGERY.
incarning, and cicatrising of wounds, or directs how to fill the
wound up with good and sound flesh and keep it to a fair and
even level with the adjacent skin, he but proclaims his own
ignorance of the properties of the living body.' What we have
to do, is to ' save the patient from immediate bleeding, and to
lay the wounded parts so cleanly, so neatly, and so evenly in
contact with each other, that they may adhere. The rest we
leave to nature.'
Sir Charles Bell,^ although imbued with his brother's
teaching, recommends the valvular method in removing loose
cartilages from the joints, and states that where the cartilage
has escaped into the joint during the operation, the consequences
are generally disastrous, on account of the exposure of the joint.
Such is a short abstract of the views held by the gi-eatest
surgeons of our country as to the effects of air on wounds ; but
whatever conclusions were come to, the good results of Aber-
nethy's valvular method were so evident that it was generally re-
commended. As we have seen, Eichter and Theden, and, I may
also say, Arnemann,^ adopted and advised it ; and Samuel
Cooper^ (1807) says of it : ' I must consider it in the present
state of surgery as the only one warrantable.' Cooper also
recommends a valvular incision for the removal of loose carti-
lages. He does not think that the situation of the incision, a
point on which great stress was laid by some at that time, is of
any consequence, but he makes it in a valvular manner, brings
the edges of the wound accurately together, and keeps the
limb extended, and completely motionless. He considers that
the dangers of such operations have been much exaggerated,
' but, making every allowance for the influence of prejudice, a
man must be very sceptical indeed who does not consider the
wound of a large joint like that of the knee attended with
real cause for the apprehension of danger.'
In 1 808 John Pearson ■* wrote against Abemethy's method
of opening psoas abscesses, and in favour of allowing them to
burst. He says : ' The instances of those who perfectly recover
from the empyema psoadicum are few in number when com-
' Princijfliis of Surgert/, edited bj'^ Sir Charles Bell, 1 826.
* System der CMrm'die, 1798. ^ Trcatixe on tlic Diseases of Joints, 1807.
* Principles of Surgery, 1808.
ASTLEY COOPER. 313
pared with those to whom it proves fatal." That his results
were not so good as those obtained by Abernethy's method is
evident from his description of the com-se of psoas abscess.
He says : ' Whether the abscess be opened artificially, or be
permitted to open by a spontaneous rupture, a very large
quantity of purulent matter, of the density of good pus, but often
inclining to a cineritious colour, is generally evacuated from its
cavity. The daily discharge of pus also greatly exceeds the
quantity that might be expected from a tumour of that apparent
magnitude. The sore frequently puts on a scrofulous aspect,
all the hectical symptoms increase, and the patient is gradually
destroyed.'
Leveille • (1812) advocated the direct incision for removal
of loose cartilages.
In America Wm. Gibson^ (1824) advised valvular incisions
in operations for removing loose cartilages from joints. He
recognised, however, that 'wounds of the larger joints are
among the most dangerous accidents in surgery ; "' and the same
may be said of those ' wounds of the smaller articulations, trivial
in the eyes of the surgeon, but, in defiance of all calculations,
sometimes followed by tremendous symptoms, and even death.'
Sir AsTLEY Cooper ^ (1819 and 1827) does not seem to
have expressed any definite opinion on the effects of air on
wounds. His method of dressing consisted in applying a piece
of lint dipped in blood along the line of incision. This
was fixed by strapping. A cooling lotion was used if there was
much inflammation. I may mention here his views on wounds
of joints. He advocates immediate and close union of the
wound in the skin. Then he applies lint dipped in blood, and
over this strapping. He covers the knee with linen soaked in
a solution of acetate of lead and spirit and places the limb on a
splint. As instances of improper treatment, he says : ■* ' If the
patient has a poultice applied, or if the utmost attention be not
paid to the immediate closure of the wound, inflammation of the
synovial membrane arises, and su})puration ensues. In young
' No\irclle Doctrine CMrvroicalc, 1812.
^ The Princijdeit and Practice of Svrueri/, 1824.
3 On iJishcations, 181!).
•* Lecivres on Snrgcry, oditcd by F. Tyrrell, 1827.
314 History of antisfptic surgery.
and healthy constitutions, these wounds in the largest joints are
recovered from, but in the aged and weak they destroy life. . .
Recovery from these injuries, when inflammation has followed,
is by adhesion, so as to destroy the synovial surface, or else by
granulation, when a partial or general ossific anchylosis is the
result.'
Larrey ^ (1829) does not believe that it is so much the pene-
tration of the air into the joint — for that very often does not
occur — as the accumulation of blood and consequent tension,
which give rise to the bad symptoms.
BOYER^ ascribes the bad results of wounds to the action of
air on them ; but he also considers that putrid pus is a bad
application. His method of treatment was accordingly to apply
masses of charpie over the wound in the first instance, and to
leave this dressing on for several days. In this way he excluded
the air till granulations had formed, and he looked on them as
sufficient protection of the wound against the influences of the
air. He therefore afterw-ards changed the dressings frequently,
in order to remove the putrid pus.
I need not go over his results in compound dislocations,
wounds of joints, &c. So far as they are given, they do not
differ essentially from the results of others. Thus six cases of
wounds of joints are detailed, of which four died, and Phil.
Boyer, who edits the work, refers to ten cases, all of which ended
unfavourably.
I have included a few writers of the present century along
with those of last century, because they merely speak of results
obtained by methods practised at that time. The whole facts
as yet stated may therefore be taken as showing the state of
surgery up to the year 1809.
Let us now methodise the results as yet obtained from an
antiseptic point of view.
The bad effects of the air, down to Priestley's discovery,
were generally supposed to be due to the temperature of the air.
Pare and others had, however, as we have seen, added to this
view the further supposition that it carried miasms to the
' Cliniqne Chiriirgicale, 1829.
* Traitv de^ 3/aladii's CMrurgicales, &c., edited bj^ P. Boyer, 1844.
WATER DRESSING: VON KERN. 315
wound ; while Benjamin Bell first spoke of the bad effects of
the gases, more especially of the ' fixed air.' We shall see
that this latter view has been more developed in recent times.
Others, looking on the putrefaction of the discharges as a
potent source of evil, attempted to prevent this by the appli-
cation of various balsams and other antiseptics ; and, in two
instances (Colbatch and Bilguer), with very great success.
Many surgeons, however, saw in the better results of their
time merely the effect of simplification of dressings, and, act-
ing on this idea, they reduced their dressings to a minimum.
Among those who held this view, and who have not been men-
tioned, were Lombaed ^ and Percy,^ who, in 1785, learaed from
an Alsatian that he had an infallible remedy for wounds. This
turned out to be river water used along with certain magic
utterances. Percy and Lombard employed water henceforth
in various ways, and became enthusiastic in its praise.
In 1809 ViNCENZ VON Kern published a little book entitled
' Avis aux Chirurgiens, pour les engager a adopter une methode
plus simple, plus natm^elle, et moins dispendieuse dans le
pansement des blesses.' In his method the wound was washed
with tepid water, left open for eight to ten hours, then united
with strips of plaster and covered with light compresses dipped
in tepid water. To provide a drain the ligatures were all
brought out at one part, or else a piece of oiled lint was intro-
duced at one of the angles. U'he wound was cleansed once or
twice daily by washing it with tepid water. In some cases he
applied poultices. He says : ' Cold water for arrest of hemor-
rhage, then warm water for the dressing, some small pieces of
lint, absolute rest, and artificial heat : see ! that is all that is
necessary for the treatment of any sort of wound.'
Von Kern held, that the ordinary methods of dressing
heated the wound and favoured inflammation and suppuration ;
that they iiritated it mechanically and chemically and, in the
case of stumps, by their weight, caused retraction of the soft
parts. He considers air as not only not hurtful, but in fact
useful. ' Folget meinem Beispiele : ' he exclaims. ' Durch
' Cliniqve Clnriirgieale relative ait.r Pfaiex, 17i)8.
2 Manuel (In Chirurgieu (VArmve, 1792. See also Ojnigcules de Medecine,
&.C., 1827.
.31G IIISTOBY OF ANTISEPTIC SURGERY.
Anwendung dieser Grimdsatze werdet ihrden Kriegern unend-
liche Schmerzen und dem Staate Millionen ersparen.'
Von Kern's method, which was essentially water dressing
— a septic dressing- — and w^hich I mention chiefly as a matter of
history, was adopted by Von Walther in Bonn, and by Fritze
in Prague. It was brought to England more especially by
LiSTON, and up till 1860 was pretty generally adopted in this
country.
It did not spread much in France ; and here is Eochard's '
explanation, which is well worthy of careful attention : ' Si ce
mode de traitement, si rationnel et si economique, n'a pas pu
se generaliser en France, cela tient surtout aux conditions hygie-
niques des hopitaux de nos grandes villes. Les Anglais, plus
favorises que nous, ne voient pas I'infection purulente incessam-
ment suspendue sur la tete de leurs malades, et c'est cette menace
qui a de tout temps preoccupe les chirurgiens de Paris. Les
pansements a Veau ne leiir ont pas offert centre elle une
garantie suffisante ; il fallait des preservatifs 'plus certains,^
ou qui du moins parussent I'etre, et a I'epoque a laquelie nous
nous reportons (1860) ils se livraient a cette recherche avec une
ardeur et une fecondite d'imagination des plus louables.'
In the further history of this subject we must, up till quite
recent times, confine our attention to the progress of wound
treatment in other countries. In England, where better
hygienic conditions prevailed, this subject was almost entirely
neglected ; and the chief aim of the surgeon was to perfect the
methods and instruments for operating, and to attain great
speed and dexterity in the performance of operations.
' Histoire de la Cliirurgic Franqaixi', 1875. - The italics are luine.
THE INCUBATION METHOD. i>l7
CHAPTER XV.
HISTORY OF ANTISEPTIC SURGERY — {continued).
History of the various methods. Incubation: Guyot. Subcutaneous surgery,
preliminary attempts: >Stromeyer : Dieffenbach : Jules Guerin : Langen-
beck : Other authors. Occlusion : Jules Guerin : Chassaignac — Rochard's
remarks : Pansement ouate — Alphonse Guerin, method and results— Oilier.
Substitution of various gases for air : Demarquay and Leconte. Open
Method: Bartscher and Vezin : Burow : Humphrey. Healing by scabbing :
John Hunter : Neudorfer : Bennion : Lister : Bouisson : Bonnet, etc.
Irrigation and the water-bath : early history : Josse : Berard : Mayor :
Amussat : Langenbeck : Vfdette.
We mu.st now trace the different modes of treatment to which
the ideas as to the cause of the bad effects which often follow
wounds have given rise.
Incubation.
As has been already mentioned, the view for a long time was
that it was the cooling and drying effect of the air on the wound
which had to be guarded against. Since Priestley's discovery
this idea has been more or less abandoned ; but in 1835 and
later, M. Jules Guyot ' studied the effects of cold, and attempted
to found a method of treatment on his views. Guyot adduces
evidence from Pare and Larrey to shew that wounds cicatrise
most rapidly in warm air. Larrey, in his ' Campagne d'Sgypte,'
states that the wounds in that hot climate cicatrise with as-
tonishing rapidity ; and in his ' Campagne d'Allemagne ' he
makes the opposite remark as to the deleterious effects of
cold. Guyot accordingly made a series of experiments on ani-
mals, and found that when wounds were kept at a temperature
' Archives Gencrak'S de Medfcine, Vol. VIII. 183.5. .See also De V Incubation
et de soil, Infltiencethcrapcutiqne,Va.x'\ii, 1840; and Z>t' la Chalcnr danslc I'raitc-
mcnt drs I'laies, 1842.
318 HISTORY OF ANTISEPTIC SURGERY.
of about 35° C, they healed with great facility, and much more
rajjidly than similar wounds left exposed to the ordinary tem-
perature.
He applied this method to wounds in man. His object was
to smTound the part with a uniform and sufficiently elevated
temperature (about 36° C, and not below 28°-30° C.) He en-
closed the wounded part, without any dressing, in a box, into
which a cmTent of warmed air was constantly introduced through
a pipe. The box had glass sides, so that the wound could be
always seen. This treatment was continued for from ten to
twenty days. At first there was a very abundant serous dis-
charge and by-and-by pus. The pus dried up, forming crusts,
which were removed every two or three days. Guyot says that
wounds thus treated heal more rapidly than by any other
method, and also that wounds, such as some forms of ulcers,
which refused to heal at the ordinary temperature, healed
readily at a temperatm-e of 36° C.
This method only merits the term antiseptic to a limited
extent. No doubt the heat made the discharge more concen-
trated, and possibly unfit for the growth of organisms, while at
the same time mechanical rest was obtained. Nevertheless, the
method did not fulfil the expectations of its introducer, and,
partly for that reason, and partly also because it was so
unwieldy, it has been completely abandoned.
Subcutaneous Surgery.
A much more important outcome of the idea of the bad
effects of the gases of the air was, however, the introduction of
the SUBCUTANEOUS method — a method which has maintained its
place up to the present time and will probably always continue
to do so to a certain extent.
Already in the last century, and indeed earlier, the founda-
tion of this method had been laid. Delacroix and Axel, by
their methods of aspirating cavities containing blood or pus,
and more especially Aberxethy, by his valvular incisions into
abscesses and into joints, had carried out the principle more or
less completely. Nevertheless it is to the introduction and
practice of subcutaneous tenotomy that we owe the spread of the
subcutaneous method.
SUBCUTANEOUS SURGERY. 319
In 1807, Sir Charles Bell advised the subcutaneous
division of the ligaments by means nf a cataract needle in cases
of irreducible dislocation of the thumb. There seems to be no
evidence, however, that he ever put his suggestion into practice.
The first real attempt at conducting an operation under the
skin was made by DELPECHin 1816.^ Delpech, in spite of what
has been thought and said to the contrary, performed the opera-
tion of tenotomy in this way in order to avoid the contact of
the air with the divided tendon. Of the air he says : ' Get agent
etait au moins un stimulant de plus qu'il paraissait prudent
d'eviter ; c'est dans ce dessein que nous avons pratique notice
operation, de maniere a ne point interesser la peauqui recouvre
le tendon.' The old method of dividing tendons was to make a
longitudinal incision over the tendon, expose and divide it.
Delpech made a small incision on each side, introduced a narrow
knife, and divided the tendon without exposing it. Unfor-
tunately suppuration occurred in his first case.
Probably in this same year Bransby Cooper divided the
tendo Achillis subcutaneously.
In 1817, Benjamin Brodie applied the same principle to
a case of varicose veins, which he divided subcutaneously.
This operation was at a later period revived by Eicord.
Astley Cooper, probably looking at division of tendons
from the old point of view, objected to subcutaneous tenotomy,
but he recommended subcutaneous division of contracted palmar
or plantar fascia, and in 1822 Bransby Cooper performed such
an operation. Neither surgeon makes any remark about the
principle on which these operations ought to be performed.
In the same year (1822) Dupuytren performed the first
subcutaneous myotomy. The muscle operated on was the
sterno-mastoid. The account of the operation is not i)ub-
lished, so far as I can find, by himself, and the accounts given
in various works differ much. It seems, however, to have
been a case of contracted sterno-mastoid in a female, and
Dupuytren divided the muscle subcutaneously, not from any
idea of excluding the air, but simply with the view of avoiding
a large scar. Indeed his incision seems to have been more
than an inch long, so that only })art of the o})eration was done
' JJc VOrthomorphii-, kc, 1828-29.
320 HISTORY OF AXTISEPTIC SURGERY.
subcutaneously, and it was not at all performed on the sub-
cutaneous principle.
In 1830 DiEFFENBACH^ spcaks of Dupuytren's operation as
having been frequently performed with success, and Syme,
among others, repeated it in 1832 strictly subcutaneously.
The various attempts at subcutaneous surgery which I
have mentioned remained, however, in the main fruitless, till
Stromeyer, and after him Dieffenbach, took up the subject.
Stromeyer seems to have performed his first operation in
1831, and his first publication was made in 1833.^ He only
operated on tendons. The object of his operation is distinctly
stated to be the exclusion of the air by making as small an
incision in the skin as possible. He looked on suppuration and
sloughing of the tendon as the consequences were air admitted.
He improved Delpech's operation by omitting one of the
incisions, simply making a single incision of sufficient size to
permit the introduction of a narrow-bladed knife. In his
'Beitrage zur operativen Orthopiidie,' published in 1838, he
narrates a great number of cases of division of various tendons
throughout the body.
Dieffenbach, who had been perforndng Dupuytren's opera-
tion pretty extensively, no sooner heard of Stromeyer's results,
than he at once adopted the practice, and his publication in the
' Archives generales de Medecine,' in 1835, narrating numerous
cases, excited the greatest interest, and along with Stromeyer's
results firmly established the method.
The most important writer on the subject, though in no
way possessing any claim as its originator, was undoubtedly
Jules Gu^rin. Though, as I have said, not possessing any
claim as originator of the method, he was the first to study,
and describe accurately, so far as the state of science at that
time permitted, the principles on which subcutaneous surgery
was based, and thus he paved the way for the more general
application of these principles. In his ' Methode souscutanee,'
published in 1841, he describes his views m detail, and gives
a number of results. His first operations were performed in
1836, and in these he remarked the constant absence of in-
' See also (Jchcr die Darchxelinruliiiui dcr Sc/inr/i itnd Miislaln, 18-11.
* Uchcr JJurvksclinciduvg dcr Achilles Schnc. linsfs JIutjaziii, Bd. iJ'J.
SUBCUTANEOUS SURGERY. 321
jflammation, and the rapid organisation of the wound. Com-
jmring his results in this respect with the details given by
Dieffenbach, Lisfranc and others, in which the frequent occur-
rence of inflammation and abscess is mentioned, he came to
recognise the principles of subcutaneous surgery to the full, or
at least so far as they could be recognised in the then state of
science. He was thus led to establish the following law :
' That all wounds made subcutaneously, whatever be their seat
and the natm-e of the tissues divided, possess the property of
subcutaneous injuries of tendons, that is to say, do not inflame
nor suppurate, but undergo immediate organisation.' Both on
man and animals he found that the most extensive wounds,
such as division of the great mass of the dorsal muscles, were
not followed by any trace of inflammatory symptoms.
He indicates some of the applications to which this principle
of making the wound under the skin may be applied. Of these
the following are the most important : Incisions into serous
pouches ; subcutaneous incision of commencing inflammatory
swellings ; subcutaneous removal of exostoses, leaving the de-
tached portion to be absorbed, or to be removed after healing
of the bone ; opening chronic abscesses ; numerous myotomies
and tenotomies of all kinds.
About this time various operations other than tenotomy
were performed subcutaneously. Thus Barthelemy, Mal-
GAIGNE and Velpeau (the two former with success) opened
ganglia subcutaneously. M. Ricord, as we have mentioned,
operated subcutaneously on the veins in varicocele. He pre-
ferred to ligature them.
DuFRESNE Chassaigne, and about the same time, or some-
what later, Goyraud and Syme, proposed and carried into
effect a subcutaneous method of removing loose cartilages from
the knee-joint, by dividing the capsule subcutaneously, expelling
the cartilage, and leaving it in a bed in the cellular tissue,
from which it could be extracted at a later period.
In England, William Adams ' published a pamphlet on sub-
cutaneous surgery in 1857, in which he shews himself a strong
advocate of the subcutaneous method. In support of the
generally accepted views as to the principles of subcutaneous
' Subcutaneous Siir'jcry, 1857.
Y
322 niSTORY OF ANTISEPTIC SURGERY.
surgery, he quotes the following passage from Paget : ' For of
the two injuries inflicted on a wound, the mechanical disturb-
ance of the parts, and the exposure to the air of those that were
covered, the exposure, if continued, is the worst. Both are apt
to excite inflammation ; but the exposure excites it most
certainly, and in the worst form, i.e., in the form which most
delays the process of repair, and which is most apt to endanger
life.'
As pointed out by Dr. Henry Dick,^ Jules Gruerin, by his
operation for removing exostoses, must be looked on as the first
to operate subcutaneously on bones. Langenbeck, however, is
the man who has popularised subcutaneous osteotomy. The
idea first occurred to him during the Schleswig-Holstein war,
in 1848, where he had introduced small straight pointed saw^s
for section of bones. His first operations were not strictly sub-
cutaneous, but in 1852 he practised subcutaneous operations for
anchylosis of the knee, and he soon extended his method to the
division of rickety bones. Meyer seems to have operated more
perfectly for rickety deformities. Gross, in 1859, j^erformed
osteotomy for deformity of the femur. This operation was
followed by abscess at the seat of fracture, but the patient made
a good recovery.
In 1869 Adams'- extended this principle to division of the
neck of the femur for anchylosis of the hip-joint.
Quite recently Ogston has divided the internal condyle of
the femur subcutaneously in cases of genu valgum. Ogston
however always operates with strict Listerian precautions, but
other surgeons still practise the operation subcutaneously,
without bad result.
Occlusion.
Attempts have been made at various times to apply the
supDosed subcutaneous principle of the exclusion of gases in
the treatment of wounds, not in the first instance subcutaneous.
I'hus have been produced the various methods of treatment by
occliislon. We have already l^ecome acquainted with the at-
' Adams' Suhciitaneoux Snrcicrij.
'■' ^1 Niiw Operation for Bony AnclujJosis of the Iliji- joint, 1871
OCCLUSIOX. 323
tempts of the ancients to exclude the air, by applying masses of
di-essings. I do not refer to these, but to the more recent
attempts which have been made since the principles of sub-
cutaneous surgery have been discussed.
In 1839, in a memoir communicated to the Academy on the
subject of subcutaneous surgery, Jules Guj^RIN ascribed its
good results to the exclusion of the air from the wound. He
further enunciates as a proposition : ' Que les applications du
phenomene de rorganisation immediate des plaies souscutanees
sont de ramener toutes les plaies avec libre communication a
Fair aux conditions des plaies souscutanees.'
From that time he tried various means for the purpose of
converting open wounds into subcutaneous ones, such as the
application of goldbeater's skin, caoutchouc, &c. ; of these he
considers, in 1844,^ that goldbeater's skin gave the best results.
In 1844 Laugier also described a similar method of treatment
in a paper entitled ' Sur I'heureux emploi du mucilage de
gomme arabique et de la baudruche dans le traitement des
plaies suppurantes.'
Chassaigxac- also brought forward an identical method, and
claimed priority over Jules Guerin. Chassaignac used the
method in abscesses, as well as in wounds. He held that the
Avails of abscesses, whether acute or chronic, resembled the
surface of a recent wound, and by opening them by a small
puncture he hoped to get adhesion of the walls. He covered
his puncture with diachylon piaster. (There is here nothing
essentially different from Abernethy's method.) Plve years
later Chassaignac said that this method had been so successful
that he had never observed a single case of erysipelas, of
phlegmon, or of hospital gangrene, even in the most unhealthy
hospitals, imder this method. Nevertheless, when he began to
work at drainage he readily abandoned occlusion.
Kochard's ^ remarks on Chassaignac's statement are very
much to the point, and well worth quoting : ' Ce n'est i)as
sans quelque etonnement qu'on voit se produire de pareilles
assertions a chaque nouvelle methode qui apparait. En les
jircnant an i)ied de la lettre, on serait force d'en conclure que
' Gazette Mi'dlcnlc, l^H. ^ Annalcs da ThcrapeKtujiie, \Mi.
' IHstoiro de la Chintnjie l'Vaii<;iiixe, 1875.
324 HISTORY OF ANTISEPTIC SURGERY.
les accidents consecutifs des plaies doivent etre a peu pr^s
inconnus dans les hopitanx de Paris, puisque tons les chirur-
giens qui y j)ratiquent se flattent de les eviter surement par la
methode qn'ils ont adoptee ; mais on ne salt que trop bien a
quoi s'en tenir sur ce point, et quant a ce qui concerne les
cuirasses de diachylon, Broca rappela qu'il avait vu mourir
d'erysipele a Lariboisiere, et dans le service meme de I'inventeur,
une femme qui avait ete pansee de cette maniere, a la suite
d'une ablation du sein. Chassaignac, du reste, ne tarda pas a
modifier son traitement en y introduisant un element nouveau,
qui absorbe bientot tout le reste : on comprend que nous voulons
parler du drainage chirurgical.'
Collodion was introduced in America in 1848, as an applica-
tion to the surface of the line of incision.
In 1866,^ Jules Gruerin developed his ideas further, and
described a complicated apparatus for the purpose, not only
of excluding the air, but also of removing the discharge. He,
unlike Chassaignac, had failed in obtaining any very satisfactory
results from the methods formerly described, and he thought that
this was because, though the impermeable material was closely
applied in the first instance, it soon became lifted up by the
discharges from the wound, and thus air got in. Then he also
feared that by that method there would be accumulations of
discharge, and that if these became putrid, their presence would
be worse than that of air. I need not enter into a description
of his method, which consisted essentially in applying an appara-
tus fitting the limb closely, and from which the air was pumped
out. In this way none of the gases of the air were in contact
with the wound, while the discharges flowed freely out. He
stated that in cases so treated there had been no inflamma-
tion, or the inflammation had been shortened and reduced in
severity.
An absolutely identical method was brought forward in 1867 ^
by Maisonneuve, as something c{uite new. The only difference
was, however, that, instead of pumping out the air once for all,
he was continually pumping it out, and he called this ' L'aspira-
tion continue.'
' Gazette Midicale. '' CoMj?tcs-reu(Ivi<, Vol LXV. 181)7.
OCCLUSION. 325
Lanxelongue also published a method, in which he used a
double-walled india rubber covering, and pumped air into the
space between its walls. The inner sac, applying itself closely
to the limb and the wound, prevented any air from coming in
contact with the latter.
There seems to be no doubt that whatever credit accrues to
any one for the introduction of these methods is due to Jules
Guerin ; and as the logical development of the view that the
noxious agents in the air are the gases of the air, these
attempts, with their failui'es, are of gi'eat interest and import-
ance.
In spite of the glowing terms in which Jules Guerin spoke
of his method, it was not found to be of any use in the hands
of others, while, what is of more importance, it broke down in
the hands of Guerin himself dming the siege of Paris. In a
discussion at the Academy of Medicine of Paris, in 1875,
on Alphonse Guerin's cotton-wool dressing, Jules Guerin was
asked about his results dm'ing the siege. He stated that at an
ambulance (I'ambulance des ponts et chaussees), to which he
was attached, he had treated only wounds by his method, but
wounds which would otherwise have led to amputation. He
said that his success was great, and that Nelaton, hearing of
it, asked him to apply his method to his (Nelaton's) amputation
cases. He tried it in three cases, all of which died, just as the
amputation cases treated otherwise did. Jules Guerin then
says : ' Cette effrayante mortalite avait sa raison dans I'infection
generale de I'hotel, qu'il etait impossible d'aborder sans en etre
averti par une odeiu* nauseabonde. . . . Je me borne a dire
qu'en presence de telles conditions j'ai refuse d'etendre au-dela
de ces trois sujets I'application de mes appareils au traitement
des amputations pratiquees dans un milieu aussi profondement
infecte.' These remarks are very interesting, as showing how
useless this method was to protect against such accidents in
situations favourable to their development, and also as showing
how very little confidence M. Jules Guerin himself had in it
when employed under unfavourable conditions.
A more important method of occlusion, and one which yields
much better results, is the ' PansemeiLt ouaU^ introduced by
Alphonse Gui-lmN in 1871. We have already seen (p. 280
32G HISTORY OF AXTISEPTIC SVllGERY.
that this is really a method of occlusion, and not an aseptic
method, as asserted by its author.
The first publication was made by Hervey ^ in December,
1871, and several details of the method and results are there
given. I shall, however, refer to this paper later, and in the
meantime take some facts from Blanciiard's ' Thesis,' '^ pub-
lished in May, 1872.
The mortality during the siege of Paris was excessively
great; indeed, Hervey says that from September, 1870, till
February, 1871, A. Gruerin only saved one case of amputation.
Gruerin, who had for some time held the view that the cause of
pyaemia was a miasm carried by the air to the wound, came to
look on this miasm as particulate, though in 1869 he seems
to have regarded it as gaseous. Acting on the view that the
miasm was particulate, he applied large masses of cotton-wool
in the hope of excluding it by filtration. There are two other
principles on which this dressing acts, which are mentioned by
Blanchard, viz., elastic compression and constant temperature.
In using this dressing, ordinary rolls of cotton-wool are em-
ployed, and cotton bandages. The cotton-wool is applied in
such mass as to allow the most energetic compression without
pain, say from a half to two kilogrammes of the wool. A region
more extensive than the wound must be enveloped in it.
The two precautions to which I have referred before must be
attended to rigorously, viz. (1) the dressing must not be ap-
plied or renewed in the ward, but in an amphitheatre or room
at some distance from the wards ; (2 ) the cotton-wool ought
not to be opened in the wards, because there the air is always
more or less contaminated. Let us suppose that we have to
deal with an amputation wound. The ligatures having been
applied, are cut short ; the wound is then washed with tepid
water, in order to see the bleeding points, and afterwards with
some antiseptic liquid such as carbolic or alcoholic water ; the
limb is then dried and the cotton-wool is laid over all the
surface of the wound, new layers being applied till the stump is
completely filled. The limb is now enveloped with rolls of
cotton-wool as fiir as the upper part of the thigh. Then the
' Pangemcnt a V Oiinte. ArcliivQS Ginu'rales dc Medccine, 1871.
- Jitudo snr Ic Panserncnt nvatc, 1 872.
'FANSEMENT OUATE: 327
bandage is applied, at first lightly, but afterwards more and
more firmly. When it is sufficiently tight, the cotton-wool
will not yield any more, and the note on percussion is tym-
panitic. If the bandage gets loose, apply a new one. If the
discharge comes through, apply more cotton-wool outside the
dressing. If the smell is very bad, wash the dressing with
camphorated alcohol, or with carbolic acid, or place pieces of
camphor in the bed. As a rule the first dressing is changed
twenty to twenty-five days after the operation. After removing
the external layers, the deeper parts are moistened with water ;
the wound is then washed with an antiseptic lotion, and a
fresh dressing is applied.
The advantages which are claimed for this method are —
suppression of pain, absence of traumatic fever, diminution of
suppui'ation, and ease in moving the patient.
Blanchard states that during the first period, i.e. from April to
the end of June, 1871, forty-one cases of amputation and resection
wei-e treated in this way, and of these seventeen died.
Deaths
1 2 amputations of the thigh .... 6
11 „ leg' 6
6 „ upper-arm ... I
4 „ fore-arm .... 1
3 disarticulations at the shoulder-joint . . 0
h resections ....... 3
41 17
3 of these cases died of pyaemia.
2 ,, tetanus.
1 amputation of tlie thigh, from secondary haemorrhage after
twenty-seven days.
1 „ septicajmia ? no metastatic abscesses ;
1 „ shock.
1 „ an infant of two months : could not
be fed.
Of the remaining eight fatal cases some were not under A.
Guerin's care, and, according to Blanchard, were not well attended to.
Others died of pyaemia, even after they left the hospital.
In the following period there were : —
1 amputation of the thigh ..... ITealcd.
1 » Kreat toe
328
HISTORY OF ANTISEPTIC SURGERY
1 amputation of the middle and first finger . . Healed.
1 „ index
1 resection of a finger
1 „ metatarsal bone
1 wound of hand ,
1 ,, index .
1 „ thumb .
1 „ extremities of middle and ring fingers
(Truly a formidable series of cases to aid one in coming to a de-
cision on the advantages of the method ! )
1 compound fracture of the radius ....
1 „ hiumerus
1 „ olecranon with opening of
the elbow-joint .
Further statistics are given by Hervey : —
1 compound fracture near the knee.
Resection, afterwards amputation,
exhaustion ..... Death.
1 amputation of thigh. High tempera-
ture and general unsatisfactory pro-
gi-ess ; injection of quinine . . „
1 amputation of first metatarsal bone Healed.
Under M. Panas at Saint Louis : —
1 compound comminuted fracture of
both bones of the leg. Gangrene,
amputation, rigors . . . ,
1 amputation of foi^e-ai-m for disease of
wrist. Advanced phthisis; diarrhoea
before opei-ation ....
1 amputation of the thigh for white
swelling ; eight days later
1 amputation of crushed foot
1 „ lower third of leg for
frost bite. Ulceration, necrosis, re-
amputation at seat of election
1 amputation (secondary) for crushed
foot
1 amputation of thigh (limb torn off')
Healed.
Death.
Sudden death.
Healed.
I give these statistics here, but I shall refer to them after-
'PANSEMENT OUATE: 329
wards. Of course, in judging them, the infected state of the
atmosphere must be taken into account.
In this method no attempt was made to obtain primary
union, but in 1875, at the discussion on this method of dress-
ing at the Academy,^ M. Guerin stated that he then stitched up
his wounds before applying his dressings, and that he frequently
got union by first intention. He said also, that in the Hotel-
Dieu he had been having good results, but he does not give any
statistics which can be used.
At that discussion, Pasteur and others pointed out that this
was not an aseptic dressing, that bacteria and their spores were
present in the cotton-wool when applied, and could be readily
found in the discharge. Grosselin, who opened the discussion,
mentioned similar facts, and he ended by saying that the dressing
was good — (I) 'parcequ'il met a I'abri de Tinflammation suppura-
tive trop intense; (2) parce qu'il satisfait a cette indication par
sa grande qualite d'etre un pansement rare, qui maintient, sans
interruption, I'occlusion, la protection, I'immobilite, la tempera-
ture imiforme, I'insensibilite, et la satisfaction morale, toutes
conditions qui, si la sante anterieure n'estpas trop mauvaise, et
si rhygiene atmospherique n'est pas trop defectueuse, condui-
sent a ce resultat tres simple, et cependant bien grand, la
formation rapide et sans etrave d'une membrane pyogenique ou
granuleuse essentielle et promptement reparatrice.'
Of late Ouerin has wet the deeper layers of the wool with
carbolic lotion, and indeed in some cases uses a spray, for what
reason it is difficult to imagine.
Verneuil ^ also speaks very highly of this dressing, and
attributes its good results to the absolute immobility which is
maintained, for by this means the granulation layer is pre-
served intact, and thus neither bacteria nor their products
can enter the blood.
That it is not an aseptic method is evident from the whole
description, and that it is not a very powerful antiseptic method
is also evident. M. Verneuil, whose good results I have just
alluded to, says of it : ' Quelle que soit I'epaisseur des couches
entassees, le bandage, au bout de quelques jours, exhale un
odeur desagreable. Le pus qui baigne la plaie est d'u7ie
' Bulletin, dc V AcaMnde dc Mcdccinc, 1875. '•' Am^mtutiuns, 1880.
ti-P,0 HISTORY OF ANTISEPTIC SURGERY.
extreme fetidite. II renferme en quantite des vibrioniens et des
bacteries, dont la putridite existe dans les profondeurs du
pansement ; et si les gennes du dehors sont arretes au passage,
ceux du dedans sont emprisonnes et forment a la blessure una
atmosphere constante. Et qu'on ne dise pas que les matieres
putrides interieiues sont d'autre nature que les autres ; car il
resulte des experiences inedites de ]M. Poncet ' que le pus du
bandage inocule a des anvmaux a toutes les proprletes des
matieres sejAiqiies.^ He alludes to the following fact of extreme
interest : ' Un eleve de mon service, tres bien portant du reste,
etait dans ce cas. 11 etait charge du pansement d'un malade
atteint d'ecrasement des oiteils, et qui etait traite par I'ouate.
Chaque fois que Veleve renouvelait le bandage, il etait pris de
Tnalaise et de diarrhee presque subite, exactement comme
lorsqu'il faisait la dissection ou I'autopsie d'un sujet putrefie.'
M. Ollier,^ who soon saw the defects in this dressing, tried to
remedy them by soaking the deeper layers of the cotton-wool
in carbolic oil. He also applied a silicate bandage outside the
cotton bandage. In August, 1872, M. Poncet gave the results
of this modification. Of 10 patients operated on, 4 died — 2 of
septicaemia, and one of hospital gangrene.
In 1875, Oilier stated that he had got great benefit from
this modification. He said that he had seldom seen a case of
erysipelas ; indeed in one winter, when it was very prevalent,
only one case dressed in this way had erysipelas, while among
the wounds treated otherwise he had 22 cases. He also thinks
that when pyaemia appears under this dressing, it is of a mild form.
Substitution of various Oases for Air.
Other attempts were made to avoid the supposed evil
•effects of the gases of the air on wounds by substituting other
gases for them. According to Kochard, these attempts were
commenced in Clifton's laboratory while Humphry Davy was
there. Perceval, then I^gexhousz, Beddoes, and John Ewart
tned to utilise the analgesic properties of carbonic acid on ulcers.
These attempts were renewed by Mojon in 1834, and by
Simpson and Follin in 1856.
• Zyo/i J/rd., 187o. 2 CovijJtcs-reiidus, Vol. LXXX.
APPLICATIOX OF CARBONIC ACID GAS. 331
Two years later Demarquay and Lecunte ^ published a
paper giving the results of an elaborate investigation on the
effects of injecting various gases into serous cavities, or into the
cellular tissue. The gases with which they experimented were
air, nitrogen, hydrogen, oxygen, and carbonic acid. They came
to the conclusion that none of these gases had any huiiful
action when injected into the peritoneal cavity, or into the
subcutaneous cellular tissue.
As to their effects on subcutaneous wounds, they state that
subcutaneous tenotomy wounds into which air is blown every
day organise much in the same manner and after the same
lapse of time as simple tenotomies. Oxygen alone, when intro-
duced daily, delays matters somewhat, but it never produces
the abnormal vascular conditions caused by hydrogen. Hydro-
gen retards the healing for an indefinite time ; indeed healing
may be incomplete even after seven and a half months. Carbonic
acid favours in a high degree the cicatrisation and organisation
of the wounds, and healing is complete in a much shorter
space of time than if the wound were left to itself.
From the result of these experiments they devised an
apparatus for the purpose of keeping wounds in contact only
with carbonic acid gas. In 1859 they say of the results : ' Many
patients affected with gangrenous ulcers, with diphtheritic
wounds or with wounds in an unhealthy state, having resisted the
ordinary methods of treatment, have been treated by us during
more than two years in the surgical department of the " Maison
municipale de Sante," and have healed with a rapidity which
was truly remarkable.' Similar experiments to those of
Demarquay and Leconte were performed by JMalgaigneIu 1844
with air, and he also came to the conclusion that air does not
impede the healing of woimds.
At the discussion on the influence of air on wounds in 1857 ^
Velpeau denied that air as such was deleterious, and said : ' II y
a longtemps que je me suis attache a demontrer qu'il agitalors,
non a la maniere d'un irritant direct, rriais en ralson des
decompositions chimiques qu'il provoque dans les liquides.
' Comj/frx-rendus, Vol. XLIX. 8cc also EhhuI dc PneuinatoLxjic Mi'd. Paris,
isor,.
- JSnllctiii dr V Acadi'-nne da Mvdcciiie.
332 HISTORY OF ANTISEPTIC SURGERY.
Ge sont ces liquides, et non pas Vair, qui, alUres, denatures y
deviennent irritants pour les tlssus qu'lls toucJtent.'*
Open inethod.
While these discussions on the influence of the air, and
these attempts to exclude the air from wounds, were going on
in France, a method of treatment, apparently of the very oppo-
site character, was being employed in Grermany with better
results. I refer to the open method of treatment.
Though Von Kern and "Walther's methods were simply the
use of water dressing, yet many of their wounds were left quite
open. But the first to use the open method properly so called
were Bartscher and Vezin. The account of their method and
work is published in the ' Deutsche Klinik ' for 1856 by Dr. Vezin.
Thirty years before that time (aboutl826) Dr. Bartscher asked
Vezin to assist him at his first amputation of the thigh. After
the operation, the dressings were applied, and the patient was
left. During the night, bleeding having occurred, Vezin
was called. He removed the dressing, and tried to find the
bleeding point, but could not do so. He therefore concluded
that the htemorrhage was due to the pressure of the dress-
ing, and accordingly he did not apply a new dressing, but
simply brought the edges of the wound together by means of
strips of plaster. Next morning this plaster had slipped, and
the wound was quite open. No further dressing was applied,
and the wound healed well.
They soon found that wounds healed perfectly well, if left
to themselves, without any interference on the part of the
surgeon ; and ultimately they laid down the following as the
best method : — Insert no stitches, apply no dressing, simplj
throw over the wound a piece of linen to exclude the flies,
and use a cage to keep off the bed clothes. The pillow on
which the stump lies is changed daily, but no attempt is
made to cleanse the wound. During the first fourteen days little
progress is made. The w^ound becomes covered with crusts,
which crack and let the pus flow out. Healing is generally
complete in eight weeks. Their cases were treated in a small
hospital, each patient generally having a room to himself in the
first instance.
OPEN METHOD. 333
Twenty-eight cases were treated in this way, with three deaths,
consisting of —
14 amputations of the thigh . . . No death.
6 „ leg . . .2 deaths.
(6 and 36 days after).
4 „ upper-arm . . 1 death.
(28 days).
2 „ fore-arm . . No death.
2 „ great toe, metatarsal „
The causes of death are not given.
In 1859 BuROW ^ published his method, which differed from
the other in that the wound was only left open for half an hour
or so till all oozing had ceased. The edges of the wound were
then brought together by means of stitches and plasters, and a
piece of lint was laid over it to keep out the flies. The stump
swells up enormously during the first few days, and Burow
thought that this was a good thing. He says that healing is
much quicker by this method than by any other. In 1866 ^ he
gives details of ninety-four amputations performed by himself
or his pupils, with only three deaths. (Two further deaths
are excluded, viz., one from tetanus which was present before
the operation, and the other in which the patient lost a great
deal of blood, and where Burow did not himself complete the
after-treatment.)
These cases were
:—
Amputation of thigh (upper third)
9:
cases (1 death).
„ (lower third)
12(
3ases(2 deaths),
j>
leg . . .
18
77
metatarsal and tarsal
bones
7
7>
j>
close to shoulder .
4
))
j>
upper arm (vipper
third)
5
>J
5>
upper arm (middle)
7
J»
>J
„ (lower third)
7
>J
>>
fore-arm (upper
third)
4
7>
»
„ (lower
third)
24
J>
' Deutsche Klinilt, 1859. '■' Deutsche Kliinh. Xo. 24.
3.^4 HISTORY OF AXTISEPTIC SURGERY.
In 1859 Burow discusses tlie causes of death in cases where
dressings are applied. He says that the bandages prevent the
swelling of the soft parts which was so very noticeable in his cases.
Pluofs of blood clot of a certain size form in the veins. When
the bandage is removed, the limb swells, and these plugs become
too small for the veins, and may be carried away, and cause
emboli and pyremia. Burow also refers to the bad practice of
using unclean sponges, instruments, &c.
In a later paper ^ (1876) he speaks of his great success in
excision of the mamma. He had operated on 53 cases during
the last ten years, without a single death. In these instances,
however, he washed out the wounds immediately before stitch-
ing them up with a mixture containing chiefly acetate of
alumina, which we now know to be a powerful antiseptic (see
p. 139). He also dressed suppurating wounds with pledgets of
lint soaked in this solution and covered with gutta percha ;
and he himself speaks of the powerful effect of the solution in
arresting putrefaction. These cases were, therefore, not treated
by the open method, but by the addition of an antiseptic
substance to the discharge, in many cases, no doubt, by com-
plete exclusion of bacteria, i.e., on the Listerian or aseptic
principle.
The chief advocate of the open method in England has been
Dr. Humphrey, of Cambridge, whose great success at the
Addenbrooke's hospital is well known. In a lecture on the
treatment of wounds without dressings (1867),^ he says: 'What
is the great requisite — the sine qua non — for the immediate
imion of wounds ? Obviously, adaptation of the cut surface.
Unless these are placed in apposition, they cannot easily unite.
Hence the want of union is commonly })roportionate to the
want of apposition of the surfaces ; and one great object in the
treatment must be to secure as exact an apposition of the cut
surfaces as possible, and to reduce to the minimum all sub-
stances, blood, dressings, ligatures, &c., that may intervene
between them, and keep them apart. In the case of small and
superficial wounds, there is little difficulty about this. Some
simple method answers, and they heal at once.' In large
wounds, the edges are brought together by means of sutures,
' ArcMr fiir Klin. Chir. XX. ^ British Medical Journal.
HEALISG BY SCABBING. 335
and afterwards no application is employed with the exception
of warm water dressing or poultices (rather opposed to the
antiseptic element !), which are occasionally applied after a few
days.
On the influence of air on wounds, he writes : ' But I am
sometimes asked, is it not better to exclude the air ? Is not the
air a source of mischief ? Is not the well-doing of subcutaneous
wounds due in great measure to the exclusion of the air ? To
this I reply that it is certainly well to exclude air from the
interior of the wound, where it keeps the surfaces apart, and
promotes the decomposition of the fluids, and perhaps of the
solids. On the surface of the wound, however, that is on the
skin, it does not act as an in-itant, and we should scarcely
expect that it would. We have long been in the habit of
leaving wounds of the face uncovered, and they usually heal
remarkably well. Why should we not follow the same practice
in other parts of the body ? ' Hiunphrey used acupressure
instead of ligatures.
The open method was for a time pretty generally adopted in
Germany and Eussia, and to Kronlein's work on the subject I
shall have to refer later. Of late, however, it has almost
entirely given place to one or other mode of treatment with
antiseptics.
Healinrj by Scahbiixj.
As we have already seen at p. 279, this is a nearer approach to
aseptic treatment than the open method. As I have previously
stated (p. 310), John Hlnter made extensive use of this prin-
ciple in the case of small wounds. He sometimes applied
various powders to aid the formation of the crust.
Since Hunter's time numerous attempts have been made to
carry out his principle of applying powders to aid the forma-
tion of crusts, but though they have answered very well in
small wounds, they have not succeeded in large. Discharges
collect l)eneath them, and tension is the result.
Among the substances employed in tliis way, have been
various antiseptics, and of these may be menti(»ned Nkudorfkk's '
powder. He uses salicylic acid, in tlie foi-)n of a jjowder,
' Dir Chirurij'iHclu' Ik'liandhiiHf th r Wiindcn, 1877.
336 HISTORY OF ANTISEPTIC SURGERY.
mixed with other substances, such as starch, zinc oxide, &c.
He dusts the wound with the powder, and rubs it up with the
fluids of the wound. Thus a mass is formed, which is again
rubbed up with fresh powder till no more fluid comes ; then
over the whole some pure salicylic acid is applied, and a bandage.
This crust is left on, and if on pressure on it some fluid exudes,
more powder is applied. This is generally necessary five or six
times during the progress of a case. This method is really only
of use in small wounds. The objections to its use in large
wounds are that the pain is great, the material is expensive,
and there is very apt to be confinement of discharge. Neu-
dorfer states that there is no bad smell in the cases treated in
this way. Among them he has had no bad case of pyasmia,
hospital gangrene or tetanus. He cannot say much about
erysipelas. As a rule, in the cases which were attacked, it was
generally some other part of the body which was affected.
Both James Moore and Astley Cooper tried to obtain crust
formation by means of char-pie, and the same sort of method
was employed by Syme. The latter surgeon, after bringing
together the edges of the wound, covered it with a piece of
dry lint, which was left on for several days.
The combination of a piece of lint tuith an antiseptic was
the method employed by Bennion of Oswestry. To quote
Wm. Adams, who mentions this treatment in his publication in
1857,^ Bennion's method in compound fracture was —
' 1st. Immediate reduction; and in secm'ing a good apposi-
tion of the fractured surfaces, he would frequently employ more
force than many surgeons might think prudent, so that he very
rarely had occasion to saw off any portion of bone.
' 2nd. He cleared away all the blood from the wound, con-
siderino' that it interfered with the reparative process, and
brought the edges of the wound into apposition. He then
covered the wound with a large bit of lint, saturated with
compound tincture of benzoin, and bandaged the entire limb,
firstly by itself, whilst extension was being kept up by an
assistant, and then to a well-fitting splint adapted to the case ;
in the lower extremity he used a straight splint.
' 3rd. He put the patient at once under the influence of
' Subcutaneous Surgery, 1857.
CRUST FORMATION. 337
opium, upon which he placed great, reliance, and kept up its
action for a considerable time, according to the circumstances
of the case.
'4th. He never disturbed the first dressing or bandage, unless
urgent symptoms indicated the necessity for so doing. If such
symptoms did not appear, he would allow the first dressing to
remain a month.' It seems that Bennion had some very re-
markable successes by this method.
Mr. Lister's first attempts to form a crust by means of
carbolic acid have been already alluded to on p. 128.
Crust formation has been aided by the drying of the dis-
charges. This occun-ed in GtUYOt's cases, though he did not
aim at it. It was, however, the principle in the often miscon-
strued method of Bouisson,i the so-called ' ventilation of
wounds.' Bouisson's method consisted in blowing air on to the
surface of a wound by means of a caoutchouc bag. He generally
directed the patient to do this himself. The ' ventilation '
lasted a variable length of time, according to the extent of the
surface and the quantity of fluid. A quarter of an hour
generally sufficed for each seance, and this was repeated four
or five times a day. The first crust which formed was rarely
sufficiently thick or firm, but by-and-by the crust became of
sufficient thickness, and when this was obtained, the ventilation
was stopped. If the crust seemed to be confining the discharge
and doing harm, it was softened and removed, and the process
begun again.
Such was Bouisson's method of obtaining a crust, and as
this method has been often quoted as shewing what a slight
effect atmospheric dust exercises on a wound, it is interesting
to note the advantages he claims for it. These advantages
are: 1. A sedative action. Bouisson says that the pain di-
minishes so much that the patients often continue the ven-
tilation for a long time. 2. Astringent action, so that the
vessels are constricted and there is less tendency to inflam-
matory congestion. 3. Drying action, i.e. the formation of a
crust. 4. This crust exercises a protective action, protecting
the wound from the air, and also lessening the quantity of
seca'etion. 5. Antiseptic action : from the evaporation and
' C'oi>H)tcs-rcndus, t. i7,"1858.
Z
338 HISTORY OF ANTISEPTIC SURGERY.
concentration of the jfluids, decomposition cannot occur. He
says : ' Le contact de I'air et de ce liquide ' (the discharges
from a woimd) ' sous Finfluence de la chaleur animale deter-
mine la formation des produits putrides sulfhydriques ou
ammoniacaux, isoles ou combines, et leur abondance contribue
a faire naitre des phenomenes typhiques ou ataxiques chez ceux
qui se trouvent places dans ces facheuses conditions. La ven-
tilation des surfaces suppurantes a necessairement pour effet
de prevenir ou d'empecher de pareils resultats, et Ton peut
dire qu'a ce titre elle est autant un moyen d'hygiene generale
dans les hopitaux qu'un artifice local pom- prevenir la resorption
putride.'
In his conclusions, in which he lays stress on the points
already mentioned, he says that wounds and ulcers so treated
heal sooner and with fewer accidents, either primary or second-
ary, than wounds treated with dressings, or with any sort of
medicament. He lays special stress on the avoidance of danger
from a septic state of the pus. He recommends the use of
this method in all small or medium sized wounds, ulcers,
bm"ns, &c.
The last mode of forming a crust which it will be necessary
to mention is by catiterisaticm. This has been resorted to by
various surgeons ; first, I believe, by Faire. An exhaustive
paper on the subject was published in 1843 by Bonnet,^ The
cauterisation may be done in various ways, either by caustics
or by the actual cautery. Of caustics Bonnet finds that the
Vienna paste or chloride of zinc alone are the best. The latter
was extensively used by M. Canquoin and also by M. Gensoul.
Bonnet remarks that after its use he has never seen decomposi-
tion occur in the wound, or phlebitis and pyaemia. Bonnet
preferred the actual cautery for various reasons. He attributed
its good effects in the main to desiccation of the tissue, and he
used the actual cautery more especially in wounds which had
taken on a bad action.
Irrif/aiion and the Water Bath.
These are very efficient antiseptic methods, and indeed, I
believe, stand next in order of efficiency to strict aseptic mea-
' See also Troitr 2>^'<it^>l>'<' fJ'' li' C(iuUnsatu>n , d\ij)rv» rcnselgxenient clmlqiir
Or A. Bonnet de Lijoii. Par 11. I'ljilipeaux, J8r)6.
IRRIGATION AND THE WATER BATH. 839
sures, more especially when the water used is impregnated with
an antiseptic.
Without entering into the older history, I may mention that
Otius in 550 praises the use of cold water in recent injuries,
and in some cases used more or less continuous, irrigation.
Again Palatius in the sixteenth century recommends the use of
continuous irrigation with cold water, and speaks of having in
this way obtained excellent results.
Two centmies later Smith ^ in England (1725) and Lamorier
in France (1732) advocated its use. Lamorier, indeed, pre-
ferred prolonged water baths to in'igation. Lombard and Percy
used irrigation, and the former also employed water baths
pretty extensively. It was not however till the publications of
JossE and Berard on irrigation in 1835, and of Mayor on the
water bath about 1836, that these methods were fully re-
cognised.
During the further progi'ess of this method, the various
questions which have been agitated are, as we shall see,
whether the irrigation or the water bath was the best ; whether
these ought to be continuous or intermittent ; what the tem-
perature of the water should be ; and whether or not some
antiseptic substance should be added to the water.
The first, as I have said, who in recent time called attention
to this subject, was Josse ; his work containing his views was
edited by his son in 1835.^ His reason for using irrigaticm
was, that in this way a continuous and more perfect application
of cold could be obtained. He used it in all the larger wounds,
and in all inflammatory states. The ap])aratus which he em-
ployed was essentially the same as that now in use.
In the same year Berard' (junior) published, quite indepen-
dently, a pa})er on the use of cold water as an antiphlogislic.
He also employed irrigation in order to obtain a constant diminu-
tion of temperature, which cannot be done, he thinks, by the
application of cloths dipped in cold water, even though they
are impregnated with substances which volatilise quickly. He
' llie C'm-iimfipx of Common Wafe); 172U.
2 Mi'lanr/tut de Cldrxmi'te prntiqne, <^'c., 1835.
^ Mvmoire tur VimpUn de I'cau froide commc atitijj/iloffi.ttiqiir dans If
traitemcnt des maladieg chiriirfficakx, 18H5.
'A 2
340 HISTORY OF ANTISEPTIC SURGERY.
mentions several cases which did very well. The only com-
plication, which he thinks is really to be dreaded, is death of
the tissues from the continuous cold ; but he says that this
rarely occurs except in severe contusions.
In 1838 NiVET ^ published a paper giving some of the results
of this method. He mentions, among other cases, nine com-
pound fractures so treated, of which seven recovered, five of
these without any local or general inflammatory symptoms. He
mentions various accidents which may occur, of which the fol-
lowing are examples : Pain (this generally soon disappears) ;
paralysis (observed in one case); oedema (combat by bandaging);
phlebitis (very rare); inflammation of the parts around the
fracture ; gangi'ene (generally only where the parts are much
injured); anchylosis or stiffness (where the partis kept for a
long time in one position).
About 1834 M. Charles Mayor published his work en-
titled ' De la Localisation des Bains sur les diverses parties du
Corps humain.' I have been unable to obtain this work, and
have had to content myself with a work published in 1846
called ' Les Bains sans Baignoires et ramenes a leur belle sim-
plicite.' His wish was to provide a permanent warm bath in
imitation of nature, for he says : * Is it with pledgets of charpie^
with rags spread with various ointments, with compresses and
with bandages, cold and dry, that nature carries out the cure ?
Nature, wise and simple nature, contents itself with calling to
its aid a warm and permanent bath, which furnishes it plenti-
fully with lubricating fluids, thoroughly diffused over the
wound, and constantly being renewed.' He points out that
this bath keeps up an equable temperature, and that nature
uses it after removal of the tonsils, after operations for harelip,
after tenotomy, cataract, abdominal section, &c., and it is to
supply its place in external wounds that he proposes the use of
the permanent warm bath. INIayor described a variety of
apparatus for use in different situations. He did not jjlace the
whole body in the bath, but merely the diseased or wounded
part. His apparatus was so constructed as to permit the
renewal of the water without removal of the apparatus. The
temperature of the water was about 22°-25° C. The baths
' Gazcttr midicale de Paris, 1838.
IRBIGA TION. 341
were employed for several clays, till in fact there was no fear of
the occurrence of accidents.
The advantages of irrigation were admitted by Nelatox,
and more especially by Malgaigne,^ who thought it best to use
it intermittingly, and so introduced ' intermittent inigation.'
Malgaigne considered that the temperature of the water ought
to be regulated by the first sensations of the patient, and
that as a rule it ought to be tepid, i.e. about 20° C. Mal-
gaigne's term ' intermittent irrigation ' applied, however, more
to a sort of water dressing than to irrigation proper, the cloths
applied to the wound being soaked in water and changed at
fi-equent intervals.
Although at first the use of water was greatly resorted to, it
soon began to go out of fashion, chiefly, it was said, on account
of the accidents to which it might give rise, and when Amussat ^
fils wrote his elaborate thesis on this subject in 1850, it was
but Httle practised. In this thesis Amussat deals chiefly with
the question of the temperature of the water. He and his
father, after long investigation of the subject, came to the
conclusion that many of the bad effects attributed to the em-
ployment of water were due to its being used cold. They found
that cold water from 0°-10° C, was a powerful antiphlogistic
and sedative, but that it was liable to do harm. Water at
30°-35° C. relieves pain in an inflamed part and promotes
suppuration : it however tends to cause congestion. Water
at 18°-25° C. has all the advantages of cold water without
its disadvantages : it abstracts heat, but does not cause con-
gestion. They recommend the use of soft water and water
containing few salts. Amussat considers that immersion is the
most effectual mode of applying water; next to that comes
irrigation, and, lastly, a form of water dressing which he
describes in detail.
Looking on imgation and the water bath simply as a means
of abstracting heat, Esmarch,^ in 1860, writes very strongly in
favour of cold, and he recommends iced water and even ice
itself. He mentions several cases in support of his views.
' De Viri'u/ation dans les maladies cMrvry'woh's. These de concours, Paris,
1842.
■' Dc I'emphn de I'eati en chirurgie, 1850.
' Archil} fur kliii Chirurgie, 1860.
342 HISTORY OF AliTISEPTIC SURGERY.
In 1872 ISAMBERT ' also writes in favour of cold irrigation,
but as there is nothing new in his work, I need not refer
fiu-ther to it.
While this discussion as to the temperature of the water
was being carried on, others were using the water bath with
the view of excluding the air and avoiding putrefaction. I
refer especially to the attempts of Stromeyer, Langenbeck and
Valette.
In spite of the writings of Mayor and Amussat, the perma-
nent water bath made but little progress till it was taken up
by IjANGENBECK. Since 1839 Langenbeck had made several
attempts to exclude air from wounds. These attempts resem-
bled those of Jules Guerin and others, previously mentioned,
but they were not successful in Langenbeck's hands, owing to
the confinement of the discharges. Accordingly, dming the
Schleswig-Holstein war in 1849, Langenbeck commenced the
use of the warm water baths with the view of excluding the
air. At the same time also Stromeyer made similar experi-
ments. During the next few years Langenbeck perfected his
method, and at length, in September, 1855, he published an
elaborate paper on the subject.^
Just before the publication of Langenbeck's paper, Picard,'
who had been visiting Langenbeck's cUiiique, published an ac-
count of his practice and results in the ' Gazette hebdomadaire de
Medecine et de Chirurgie.' In this paper he speaks very highly
of the method, showing how it relieves pain, how there is but
little local inflammation or constitutional distiu-bance, how the
appetite remains good, how granulations form rapidly, so as
indeed at times to be exuberant, how there is no odoiu-, and
how this method seems to protect the patient against the
chance of pyaemia better than any other. In contrast with this,
he describes, in a very graphic manner, the course of a wound
treated by the ordinary methods — a course common at that
time, and indeed, as I have myself seen, by no means uncom-
mon at the present. He says : ' Deja, grace au chloroforme, la
' Considerations cliniqnes sttr leu ho/is effets de VirHgati4)n continue et des
ajjjjlications froides renouveUes dans le traitement des fractures are jjlaie.
Those, 1872.
2 Deutsche Klinik,'No. 37, 1855.
' Gazette hehdontadairc de Mrdeeine et de C/iirnrffie, lSo5.
WATER BATH—LANGENBECK. 343
douleur disparait au moment decisif; I'homme vivant est
insensible sous le bistomi ; ses lamentations ne viennent plus
interrompre I'operateur. Mais apres avoir depasse le seuil de la
salle d'operation, des que la torpeur anesthesique s'est dissipee,
le patient, abattu, affaibli, voit s'ouvrir devant lui tout un
avenir de souffrances. La douleur, un moment comprimee, se
dechaine avec violence. Plus de repos, plus de sommeil. Les
terribles secousses de la fievre inflammatoire epuisent le malade
et compromettent le succes de l'opera4-ion. Les tortures quo-
tidiennes du pansement viennent aggraver cet etat general.
Qui n'a pas eu le coeur serre en entendant les plaintes ar-
rachees par le moindi'e mouvement de la partie operee, par le
tiraillement des brins de chaqjie agglutines, par la pression
grossiere et inegale du bandage, sans compter I'atmosphere
infecte dans laquelle le malade et ses voisins sont condamnes
a vivre, les souillures des draps et des couvertures ? Enfin, la
nature est derangee dans son travail reparateur ; chaque tour
de bande change les conditions de la plaie, et le chirm'gien ne
pent lui-meme diriger la guerison '
Langenbeck placed the wounds in the bath immediately
after operation. Where possible, he stitched up the wound,
leaving a space at the angle through which discharges passed,
and through which the ligatures were brought out. Dming
the first twenty-foiu- hours, the limb was simply suspended in
a bath, and was not arranged in one of the apparatuses which
are apt to constrict the part and cause bleeding. When the
edges could not be brought together, charpie and a bandage
were applied for the first twenty-four hours to prevent bleeding.
The permanent bath was continued till granulation was
complete, and till epidermic formation had commenced. The
limb and granulations were apt to become oedematous, but this
subsided in a few hours after the removal of the part from the
bath. The apparatus was emptied night and morning, and
the walls of the vessel carefully sponged with water con-
taining chlorinated soda or chloride of lime. When the stump
had been closed at first, the wound was daily injected along
the course of the ligatures. The temperature of the water
was at first 10°-12° C, but it was raised, as the patient could
bear it, to 31°-37° C. The skin of the slump had a thick
344 HISTORY OF ANTISEPTIC SURGERY.
layer of grease over it, to prevent the action of the water on the
epidermis. Where the whole body had to be immersed, the
immersion was continued for a half to one hour daily in water
at the temperature of 34° C. Water dressing was employed
towards the end of the case.
Langenbeck gives the following as the advantages of the
permanent water bath : —
1. It diminishes pain in the wound, and also does away
with all painful dressings.
2. The intensity of the fever is less.
3. Stagnation and decomposition of discharges are com-
pletely prevented.
He says that in wounds so treated, union by first intention
is rare, though not unknown.
Among the cases treated in this way he had had, during a
period of five or six years, no instance of pyaemia, although, as
he says, some of the cases were very well suited for its occur-
rence, and although pysemia was prevalent at the same time in
other wards and even in cases in the same ward. He says :
' Cooling of the wound, retention and putrefaction of the dis-
charge, and miasmatic influences (hospital air) are the causes
of pysemia. These noxious agents can be completely excluded
by the careful employment of a water bath.' He also believes
in the spontaneous occurrence of pysemia, through constitu-
tional and blood defects, and he does not think that these rare
cases would be prevented. Then, also, decomposition of the
discharges in a complicated wound is quite possible, even in a
water bath, and might lead to pyaemia. He mentions several
(7) cases to show the good results. It is interesting to note
that one of these — the only fatal case — was one in which,
during the removal of a tumour, the knee-joint was opened.
Violent inflammation and suppuration of the joint followed and
the patient died on the twenty-first day.
Langenbeck's paper was followed a month later by one by
Dr. FocK.^ He confirmed Langenbeck's good results, compar-
ing together cases of Pirogoff's amputations treated by the
warm bath, with others treated by the ordinary methods, much
to the advantage of the former. He mentions also that Dr.
> BenUchc Klinik, Oct. 1855.
WATER BATH—VALETTE. .'345
Wagner of Dantzic, who had adopted it, reported that formerly
i:)ygemia was very prevalent in that hospital, but that since
the introduction of the warm water bath it had almost entirely
disappeared.
In a paper in 1856, Picard' mentions that Gosselin and
I^AUGIER had adopted this method, and Fock also refers to
Ulrich.
In October 1856, Zeis of Dresden published a note entitled
' Beitrag zur Wiirdigung des permanenten warmen Wasser-
bades," ^ in which he advocates the use of a still higher tempera-
ture than that recommended by Langenbeck. Zeis finds that a
permanent bath below the body temperature is seldom endured
by the patient. The best temperature is 37°-42° C. For am-
putations 35°-37° C. may be sufficient.
It is unnecessary for me to pursue the history of Langen-
beck's method further. It is the one generally adopted where
immersion is employed, and for some time it was very exten-
sively used in Grermany. It has of late gone out of use, not
because its results are not good, but because it is difficult and
inconvenient of application, and because it can now be replaced
by more effectual and simpler methods.
Before leaving this subject, however, I must do justice to a
method in which the antiseptic element was more fully recog-
nised, and in some respects better carried out, but which has,
very strangely, not attained any prominence, probably because
the name of its author was eclipsed by the better known name
of Langenbeck. I refer to the method proposed, and, while he
had opportunity, carried out by Valette of Lyons.^
Valette's view was the following : ' The safety of sub-
cutaneous wounds sufficiently demonstrates that the presence
of the air in the wounds is the primary cause of their bad course.'
* How does the air act ? This is a delicate question, but the
following is the explanation which appears to me to be the fairest.
As soon as the operation is finished the blood and the liquids
which collect on the surface of the wound, decompose under
the influence of the contact of the air. Sulphuretted hydrogen
' Gazcite helxhimadairr, 1850. ^ DeuUrhr KliiriX October, ISoG.
" Sur vne twiirelle mvthode de panacment des grandes jjlait's {wvt/iode
anaf.roplast'ique), Gazette hehdumadaire, 1856.
346 HISTORY OF ANTISEPTIC SURGERY,
and putrid gases, if you will pardon this expression, are formed
and absorbed in part, and exercise a deleterious influence on
the body. In a word, there is a true poisoning of the patient,
which the constitution often withstands, though not always,
especially when the patient is placed in unfavoui'able hygienic
conditions, as is the case in the wards of our hospitals. In
these cases the phenomena of cicatrisation do not proceed in a
favom-able manner, suppurative phlebitis occurs, and pus passes
into the circulation ; purulent absorption is an accomplished
fact, and death is, one may say, an almost inevitable conse-
quence.'
To avoid these dangers Valette immersed the wounded part
in baths containing water impregnated with tincture of benzine,
creosote, alcohol, or perchloride of iron. The last gave the best
results. There was no putrefaction of this fluid, and he seems
to have had great success. He was especially struck with the
absence of traumatic fever.
PuPiER,' who wrote his thesis in 1855 on Valette's method,
mentions a number of cases which did well, and states that, in
order to prevent the water from getting too warm, it was in
one case changed as often as thrice daily.
Valette had only a limited opportunity for caiTying out his
experiments, for after a short time he was placed in charge of a
children's ward, where he could no longer practise this method.
' U'un traiUvient conseoutif ijjecial des amimtatiom. TMse, 1855.
USE OF ANTISEPTICS. 347
CHAPTER XVI.
HISTORY OF ANTISEPTIC SURGERY — (concluded).
Use of antiseptics : Alcohol — older writers — Nelaton — Hutchinson : Glycerine
— Demarquay : Chlorine : Chloride of zinc : Iodine : Iodoform : Chlorate
of Potash : Perchloride of iron,&;c. : Coal tar — Corneand Demeaux — Report
of the commission : Coal tar saponine — Lemaire — his views on putrefac-
tion : Carbolic acid — Lemaire — Lemaire"s position in regard to aseptic
surgery — Lister : Further phases in the history of this subject : Objections
to Mr. Lister's claim as originator of the aseptic method — Simpson —
Neudorfer. Modifications of the method. Substitutes for carbolic acid.
Objections to the aseptic method.
The last point to which we have to refer is the use of antiseptics.
As we have already seen, various antiseptics have been in
use for many centturies as applications to wounds, and some
surgeons indeed have ascribed the good results, derived from
their use, in the main to their anti-putrescent properties. In
spite, however, of the attempts of surgeons at different times
to draw attention to these properties, it was not till the publi-
cation of Come and Demeaux's method in 1859 that general
interest in the subject was aroused.
Among the substances formerly employed, alcohol was pro-
bably the one in most extensive use, and after the subject of
antiseptics came to the front, it was freely employed in some
quarters. As I have just said, alcohol was formerly used in
great quantities, but then it was generally combined with other
substances, though it probably was really the active basis of
the compounds so prepared. Thus the balsam of Fioraventi — a
celebrated appHcation to wounds — consisted of turi)entine,
myrrh, aloes, a large quantity of alcohol, and several unim-
portant substances. Many of the various lotions which have
been most popular at different times had a similar constitu-
tion.
348 HISTORY OF ANTISEPTIC STTUGERY.
Bataill]^ ' published a little pamphlet in 1859 advocating
the use of alcohol, but it was most extensively adopted by
Nelaton in 1863, and also by Le Fort.
Chedevergne^ in 1864 published a detailed account of
Nekton's practice with the results which he had obtained.
Nelaton's method was to soak chm'pie with camphorated alcohol,
and apply it over the wounds in thick layers. These were
either kept wet by frequent arrosion, or were covered with an
overlapping layer of impermeable tissue, or in some cases the
dressing was changed twice daily. Patients treated in this
way remain in good health, the edges of the wounds adhere,
no granulations are formed, but the wound becomes covered
with a layer of lymph under which cicatrisation rapidly occurs.
This is the rule, though not an absolutely constant one. In
open wounds the granulations can scarcely be seen. There
is an abundance of coagulable lymph, almost no appreciable
suppuration, and no bad smell. In some cases the charpie
becomes embedded in the coagulated albumen, and the whole
dries up and forms a crust.
Chedevergne says that, for more than a year, operation
wounds, and injuries, had been treated with camphorated
alcohol, or with pure spirits of wine, and that during that time
pysemia and other infective diseases had been almost entirely
absent. Of forty-eight patients who had undergone severe
operations, only three died ; one of tuberculosis, one of hypo-
static pneumonia, and one of pysemia.
RocHARD ^ gives later statistics, in which he shows that there
were only two cases of pysemia, and five of erysipelas. Good
success in the Hopital des Cliniques !
On a pre\dous page (p. 269) I have referred to Mr. Hutch-
inson's method of using alcohol. He mixes it with acetate
of lead somewhat after the manner of Astley Cooper.
Glycerine was used pretty extensively in England after
1 840, but was introduced in the treatment of wounds mainly
by I)p:marquay in 1855.* He first employed it in cases of hos-
' iJe Valcool et dcs covqjoscx alcooUqvcs en Chirvrgic. Par JIM. Bataill6 et
Juillet, 1859.
^ Bulletin general de Therapentiqve, vol. Ixvii. 1864.
' Loc.cit. * Gazette des ffdj^itaiix, October, 1S55.'
USE OF ANTISEPTICS. 349
pital gangrene, and he found that they rapidly began to im-
prove under its use. He then extended the treatment to
ordinary wounds. He claimed all sorts of advantages for it. In
1859, more especially, he stated that it was a specific against
erysipelas, pyaemia, hospital gangrene, &c. He thought that it
was the best antiseptic substance, and indeed a universal
panacea. Since that time it has, however, been extensively
tried and found wanting, and has, as Rochard says, for a long
time been justly relegated to the modest place in therapeutics
which nature had assigned to it.
Ghlo7%ne and its compounds have been used as disinfec-
tants ever since its discovery in 1774. Guyton, in 1795, re-
commended its use in hospitals by fumigation, in order to
destroy miasms. The Liquor de Labaraque, which attained
considerable notoriety as a disinfectant, consisted mainly of
chlorinated soda. In more recent times the chlorine com-
pounds, more especially chlorinated soda and chloride of lime,
have been employed in the treatment of wounds, the wounds
being washed or syringed out with the solution, and dress-
ings applied which were frequently moistened with the same.
Hervieux applied a sponge soaked in the solution to the
wound, and this, according to him, not only disinfected the
discharge, but also absorbed it. M. Gueesant also used it
largely.
Chalvet ' recommends the introduction of chloride of lime
into the superficial layer of the charpie. Chlorine is given off
from this, and prevents the decomposition of the discharges.
We have already mentioned chloride of zinc, which, as we
have seen, was extensively employed as a caustic by Canquoix
and Gensoul. Bonnet also used it, and remarked on the absence
of putridity in the wounds made by it. In more recent years
Campbell de Morgan has again used it as a caustic, and also
made the same remark as to its antiputrescent powers. It thus
came to be employed as a lotion in the treatment of wounds,
but it has never become extensively used. The chief use to
which it is put nowadays is by Mr. Lister in disinfecting foul
ulcers or sinuses (see pp. 65 and IIG).
' Bes drxiitfrctants et de Iciir applicatwii, a la Tlivrapcutiqiie ct a I'llijtjihie.
Mciiioire do V Academic ivijjcriulc dc Mcdecinc, vol. xxvi. 1863.
350 HISTORY OF AXTISEPTIC SURGERY. '
Velpeau in 1859 stated that Iodine had been in use as a
topical application for over thirty years. On the contrary,
DuKOY asserted that it was only as a consequence of a com-
munication made by hira in 185-1 that iodine was first em-
ployed in wounds. Iodine has at times been used in the prac-
tice of various surgeons. Thus Mr. Spence of Edinburgh at
one time painted the surface of stumps with iodine, and
thought that he got good results from it ; however, he soon
took to painting stumps with other things, and the iodine
fell into disuse.
The only preparation of iodine which is now employed in
the treatment of wounds is Iodoform, which is of great use in
chancres or foul ulcers. I have already referred to the method
in which it is applied in the latter cases (pp. 65 and 94).
Various metallic salts have been from time to time intro-
duced, such as Chlorate of Potash by Milton. This acts very
well in ulcers in the mouth, but is not of any very gi'eat value.
Perchloride of iron was employed as a disinfectant by
Deleau, and I have already referred to the use which Valette
made of it (p. 346).
Nitrate of lead, subnitrate of bismuth and other powders
have also been spoken of at various times.
During the middle of the present centmy there had been
constant efforts made in various directions to diminish the
great mortality in French, more especially in Parisian, hospitals
by means of some method of wound treatment. We have seen
how at first it was chiefly the action of the air on the wound
which was guarded against, but in 1859 it had come to be fully
recognised that the chief thing which was required was to
prevent decomposition of the discharges. It is therefore not a
matter of suqwise that when Corne and Demeaux in that year
brought forward a powder which they believed to be capable of
attaining this object, attention was at once directed to the
subject, and not only did debates occur in the scientific
societies, but experiments were also made in the various hospi-
tals with this and other antiseptic substances.
Already in 1815 the antiseptic and disinfectant properties
of coal tar had been recognised by Chaumette, and Guibouit
(1833) and Siret (1837) also wrote on the subject. In 1846
ANTISEPTICS— CORNE AND DEMEAUX' POWDER. 351
Bayard introduced an excellent disinfectant, of which the chief
ingredient was coal tar.
In 1858, M. CoRXE took out a patent for a powder which
he had for some time employed as a disinfectant, and in the
same year Demeaux ' used this powder in the treatment of
wounds. The powder employed by Come and Demeaux "^ had
the following composition : of ordinary plaster of commerce in
very fine powder, 100 parts ; of coal tar (obtained from dis-
tillation of coal in the manufacture of gas), 1 to 3 parts. These
substances were readily mixed together in a mortar, and then
olive oil was added till they acquired the consistence of paste.
This paste was applied to wounds, more especially to foul
wounds, and it was found that it disinfected (deodorised?) the
discharges at once, and that it also absorbed them. They
stated that, ' the action of this disinfectant substance seems to
arrest the work of decomposition ; it keeps away the flies, and
prevents with certainty the production of worms.' Their ex-
periments were made jjartly in private practice, and partly in
Velpeau's wards. Velpeau observed that in the cases treated
in this way suppuration was also diminished.
In the discussion which ensued at the following meetings
of the Academy, various opinions were expressed as to the use
of antiseptics in general, and as to the action of this particular
powder.' M. Chevreul found that the coal tar powder did
not destroy the odour, but rather cloaked it, while, on the other
hand, hypochlorite of lime in large quantities made it disapj)ear.
He thought however that the coal tar powder would act in
preventing putrefaction. M. BusSY called attention to the
fact that other disinfectants were in constant use, and were
also employed to prevent putrefaction. Such were carbon,
chloride of lime, soda or potash, creosote, &c. 31. Kenault
stated that as long ago as 1840 he had published a memoir on
disinfection of wounds ; for at that time he had come to the
conclusion that the putrefaction of blood and discliarges, and
the contact of these putrid materials with the wound, were the
cause of the bad after-conseqilences. He had found that
hypochlorite of lime was the best, though in some cases the
' L'ninn mt'dieale, I8(i0. - BitUetin dc I'Aradi'mie dc Mcdecine,\^o^.
' Jhid. : see also Gazette mcdicale de I'aris, 18GU.
35 J HISTORY OF ANTISEPTIC SURGERV.
disengaged chlorine irritated the lungs. Hence he welcomed
the coal tar powder, but he stated that vegetable tar acted as
well and had a less disagreeable odour. Calvert had previously
shown that carbolic acid, which was present in coal tar, was a
powerful disinfectant, and, at a later meeting of the Academy,
he stated that it had been used in Manchester in 1857, in the
preservation of dead bodies, with success. Dumas had stated, at
a jirevious meeting, that carbolic acid was present in coal tar
in small quantities and that the least trace of carbolate of
soda was sufficient to preserve animal matters.
After the reading of Corne and Demeaux' paper and the
subsequent discussion in the Academy, a commission was ap-
pointed by the Academy to enquire into the matter. This com-
mission consisted of Chevreul, J. Cloquet and Velpeau. As
the result of their investigations, they concluded that this
powder was most useful for disinfecting substances, but that
it was not a convenient application to wounds, that its odour
was disagreeable, that it had often to be renewed and that it
soiled the linen. Lemaire also adds that it solidifies and pre-
vents the escape of pus.
The commission tried various other substances which had
been mentioned, such as glycerine, sugar, chlorate of potash,
&c., but found that they were not much better than ordinary
cerates. Tincture of iodine was found to act fairly well, but
to cause too much pain ; chlorine and the hypochlorites were
good. Sub-nitrate of bismuth or perchloride of iron used in
the form of an ointment (8 grains of the liquor to 30 grains of
lard), were excellent applications.
Corne and Demeaux' powder soon disappeared from the list
of remedies, but nevertheless attention was attracted by it to
the subject of antiseptic applications to wounds.
Among those who spoke at the debates was Le Bceuf, who
in 1850 had found that substances insoluble in water, but
soluble in alcohol, could be made into an emulsion by the
addition of saponine. Such emulsions were very fine and very
stable. Le Ba>uf proposed that coal tar should be emulsionised
by the aid of this tincture of saponine.
Jules Lemaire at once took advantage of Le B«uf s sug-
gestion, and in 1860 he published a paper on ' Coal tar sapo-
LEMAIRE—COAL TAR SAPOXINE. 353
nine.*' The tincture of saponine, to which reference has ju.st
iDeen made, is an alcoholic extract of the bark of Quillai/a
saponaria and contains other substances besides saponine. A
tincture of ' coal tar saponine ' was made by mixing together 1
part of coal tar with from 2 to 4 parts of tincture of saponine.
With this an emulsion was made by mixing 1 part of the
tincture with 4 parts of water. This emulsion retained all the
properties of coal tar, and is the substance which was used by
Lemaire. Lemaire investigated the "activity of its various
constituents, and found that it contained saponine which
acts as an antiseptic; alcohol, nlso an antiseptic ; carbolic acid,
a powerful antiseptic, but apt to cauterise the tissues ; benzine,
which is an irritant ; naphthaline, which is a sedative, and,
in Lemaire's opinion, ' modifies and tempers the action of the
other substances.'
Lemaire applied this emulsion very extensively in the
treatment of a variety of diseases, and also to putrid wounds
and ulcers. The results of its use in the latter cases wer^ —
1. Disinfection of the wound; 2. The wound assumes a rosy
aspect ; 3. The sloughs become detached with greater facility
than usual ; 4. It only exceptionally causes pain. Lemaire
also states that it acts powerfully in reducing the quantity of
pus secreted. This emulsion was applied in the same manner
as other lotions. The wound was washed with it, and then
dressed with charpie soaked in the emulsion. I cannot find
any case illustrating its use from the time of operation. There
is no sort of system described, and I^emaire seems to have
used it merely as a disinfectant and as a good apj)]i('ation to
wounds. Li fact he treated tlie wound with antiseptics, but
not aseptically. Numerous letters from various surgeons are
published in Lemaire's book shewing tliat smell was destroyed
at the time of the application, but that in some cases the dis-
charge became foul before a fresh application was made.
His views on the germ theory of putrefaction are of the
greatest interest, as he was undoubtedly the first who, recognis-
ing that theory, applied it to practice. He says, ' the wound
which suppurates, as I hope to demonstrate presently, is a
secreting surface, the products of which become altered under
' Do coal tar saponine, 186f^.
A A
854 HISTORY OF ANTISErVIC SURGERY.
the influence of air and give birth to a series of phenomena due
to one and the same cause, fermentation.' He believed that
pus at the commencement is sim})ly serum of the blood con-
taining fibrin, that fermentation occurs in this from contact
with the air and that pus corpuscles correspond in their nature
to yeast cells and are the result of this fermentation. Novs^ coal
tar sapouine at once arrests this fermentation and consequently
this formation of pus cells. I have already referred to Le-
maire's experiments on putrefaction and other fermentations
(p. 218). He concludes that the two principal properties of
coal tar saponine are disinfection and arrest of fermentations.
' A third important property which seems to me to be the cause
of the arrest of the fermentations, is the toxic action which
it exercises on vegetables and on the lower animals.' It
favours healing by disinfecting the wounds and arresting the
fermentation of pus. He concludes that the germ theory of
fermentations is true, and that coal tar arrests and prevents
fermentation by its toxic effect on the lower organisms which
cause them. He says again: 'These facts make me think, that
it is on account of its toxic properties on vegetables and on
the lower animals that coal tar can prevent or arrest fermen-
tations. The opinion of Schwann and of several other physio-
logists, a view which in the present day has received great
support from M. Pasteur, ap])ears to me to be true.' . . . ' As
the ferments appear to be the infusoria and the microscopic
vegetable organisms which exist in abundance in the atmo-
sphere, and as the " coal tar saponine " destroys them, let not
physicians forget this precious property. Perhaps it may
■penn'd them to make imjpoi'tmit discoveries, mid to render
a great service to hum^anity.^ '
While Lemaire was using this coal tar saponine he was also
experimenting with carbolic acid. He found that carbolic acid
could form a 5 per cent, solution in water, <ind could also be
dissolved in oil and alcohol. He found too that it was much
more powerful than coal tar, but that its volatility and its
powerful action on wounds were disadvantages. On the other
hand, with carbolic acid he had a solution of known and constant
strength, which mixed with the discharge and soaked into the
' Tlie italics are mint'.
LEMAIRE— CARBOLIC ACID. 355
tissues more readily than the emulsion of coal tar. He pub-
lished a work on the subject in 1863, called 'De I'acide pheni-
que,' and such was the interest excited in France by this work
that in 1865 a second edition appeared.
The greater part of his work is taken up in discussing
the germ theory, which he advocates, but the experiments,
though numerous and laborious, are so crude and imperfect
that I have not been able to make any use of them,
though I had much wished to do so, if only for their historical
interest.
In applying carbolic acid to medicine and surgery, he seems
to have been guided by no principle or rule, but simply to have
applied it empirically. Thus the following is a list of some of the
diseases in which he used it : acne, anthrax, asthma, cholera,
dysentery, ecthyma, eczema, erysipelas, intermittent fever,
typhoid fever, herpes, impetigo, lichen, purulent ophthalmia,
pityriasis, phthisis, prurigo, sycosis, cancerous ulcers, taenia,
smallpox, &c. In cases where it did good it was supposed to have
killed germs. He used it also in ulcers in the same way as
the emulsion of coal tar, and where tortuous canals existed,
the lotion of the strength of '2 to 1 p. c. was injected. He says
very little about recent wounds ; indeed the following is about
the only passage I can find. ' Pour mettre les solutions de
continuite des tissus a Tabri de la fermentation il suffit de
les couvrir des le debut avec des compresses, constamment
imbibees d'eau pheniquee. Deux milliemes de I'acide ])henique
suffisait dans ce liquido pour obtenir ce resultat.' How ver}'
imperfect such a method would be, experience and experiment
have since am})ly shown. He only mentions having treated one
case of compound fracture, a fracture oftlie fingers, in which he
used the emulsion of coal tar.
Here there is nothing which can b(^ called a melluxl.
Lemaire realized what the causes of putrefaction were, but he
made no attempt to exclude them, nor indeed did he make
any systematic attempts to ei-adicale them after tliey had
entered.
In 186,5 Dkct.at published a work on carbolic acid in which
he claimed piiority over Lemaire. This w<tik contains no
observations of any value, and liis claim of priority is absolutely
356 HISTORY OF ANTISEPTIC SURGERY.
without foundation, for Lemaire began his work before Declat,
and Declat was well acquainted with Lemaire's work before
publishing.
We must in a few words enquire what is Lemaire's 'exact
position in reference to antiseptic surgery ? how much does
the present advance of antiseptic surgery owe to him? It is
a question which for a time has been much debated and
variously answered.
In the first place we find, as I have already stated, that
Lemaire recognised the true basis of antiseptic surgery, the
germ theory of fermentation, and also that he was the first to
use carbolic acid extensively in the treatment of wounds. But
we do not find any method of how best to add the antiseptics
to the discharge or how best to exclude organisms altogether.
All that we find is that certain results — absence of smell — were
attained, and the explanation was that the carbolic acid had
destroyed the causes of fermentation. Then, also, look at the
aimless way in which he applied carbolic acid to all sorts of
diseases. There was no definite plan, no clear purpose, in
these attempts.
On the other hand, we must remember Lemaire's opportuni-
ties. He had no hospital appointment as surgeon ; no oppor-
tunity, therefore, for seeing a sufficient amount of surgical
practice to realise the necessity for systematic action. Would
he have elaborated any aseptic, or even thorough antiseptic
method had such op})ortunities been given him ? I cannot say,
but I doubt it, for his experiments shew the same want of
purpose and imperfection in inference, while his views on pus
cells, and many other points, show an im})erfect appreciation of
the elementary facts of physiology and pathology.
I am not, however, concerned with what he might have been,
but with what he tvas ; for indeed, as Carlyle well remarks, ' it
comes that these same would-have-heens are mostly a vanity,
and the world's history could never in the least be what it
would, or might, or should, by any manner of potentiality, but
simply and altogether what it is.^ Lemaire tvas the first to use
carbolic acid, and was the first to realise the truth of the germ
theory as applied to wounds. lie tuas an advanced treater of
wounds with antiseptics, nothing more.
SUMMARY UP TO 1867. 357
The use of carbolic acid in the treatment of wounds was
for some time tried extensively on the continent, and in Eng-
land it was also employed by one or two surgeons (Wood,
Spence) ; bat, applied in the way recommended by Lemaire,
it failed to give satisfactory results and soon began to di'op out
of use. Indeed, as early as 1867, Dr. Hingston, who had been
travelling on the continent, stated, at the Dublin Meeting of
the British Medical Association, that ' he had found that the
use of carbolic acid in surgery was now being discontinued in
places where it was formerly in vogue.'
The result of these centuries of work on the subject of
wound treatment may be summed up as follows. The old
views, that wounds could not heal without active intervention on
the part of the surgeon, had been thrown aside, and, after many
oscillations of surgical opinion, it had at last become generally
recognised that nature was the sole agent in the reparation of
wounds ; it had, however, become apparent to most men that
the decomposition of the discharges in wounds was a source of
danger to the patient so great as to demand active interference
for the purpose of preventing it as far as possible. The various
attempts which were made with this aim are most interesting
and important, although they were all more or less inefifectual.
On the supposition that the gases of the air were the active
agents, numerous methods (occlusion, crust formation, substitu-
tion of other gases, &c.) had been devised for the purpose of
excluding the air, but these had all failed in producing any
permanent benefit ; it was rendered clear from these researches
that the gases of the air were not the injurious elements.
Subcutaneous surgery, though based on this erroneous view,
had ])ecome firmly established, and it was universally recognised
that, if an operation could be done subcutaneously, it was to a
great extent free from danger ; unfortunately, the appliealiility
of this method was very limited. Then, at first with the view
of regulating the temperature of the wound, various forms of
irrigation and water-baths were introduced. Some of the
surgeons, however, who employed them observed that decom-
position was less, and that this was due in great measure to the
washing away of the discharges. Drainage had also to a certain
358 HISTORY OF ANTISEPTIC SURGERY.
extent, though imperfectly, been introduced." On the other
hand, it had been found that, by the addition of various
substances, hence termed 'antiseptics,' to the discharges of
wounds, decomposition could be markedly interfered with, and,
at the time to which we refer, in France more especially this
idea was the most prominent in the treatment of wounds. One
surgeon, indeed, Lemaire, had announced the view that anti-
septics acted by destroying ' the vegetables and lower animals '
found in these discharges, and which appeared from recent re-
searches to be the active agents in producing decomposition.
Lemaire, however, failed to follow out his views, and thus missed •
the discovery which was very shortly afterwards announced by
Mr. Lister.
Such was the state of matters when Mr. Lister, who had
been working for more than two years independently of any
knowledge of Lemaire's e:^periments, published his first papers
on aseptic surgery, w^hich at once threw a flood of light on the
confused subject of the treatment of wounds. The develop-
ment of his system in his own hands has already been traced.
Mr. Lister's writings have stimulated surgeons to the study of
the whole subject, and have led to the introduction of improve-
ments in every detail of wound treatment. These improve-
ments, acting on better principles, have brought even the older
methods to a high state of perfection, and numerous researches
have since been made which have enabled us to reduce to order
and show the true principles underlying the various attempts at
wound treatment which had been previously carried out.
It would be hopeless to attempt to follow out all that has
been said and written on this subject since that time, and it
would not only be hopeless but also profitless, for the greater
part of the statements rest on imperfect understanding or know-
ledge of Mr. Lister's writings, and imperfect acquaintance with
the scientific advances of the present day. In Germany, where
science is more advanced than in other countries at the
present time, this method has been almost universally accepted
and introduced, and some of the leading German surgeons are
amongst the most enthusiastic supporters of it. In our own
' Cliass,ai_i,mac : Tra'dv jtruiUjve dc la Hitppuruilon ct dti. Drainage CMrvr-
(liralr. ISoO.
SPREAD OF ASEPTIC SURGERY. 359
country on the other hand, the necessity for a protection against
infective disease has not been so much felt, on account of the
much better hygienic conditions of our hospitals ; while,
owing to our so called practical nature, the scientific problems
involved have been allowed to fall out of notice and have
been imperfectly appreciated when noticed. Perhaps the
greatest obstacle to the acceptance of the principles of antiseptic
surgery is the confusion which has somehow or other arisen
between the germ theory of fermentation and that of infective
disease. Indeed at the present time nine surgeons out of ten,
if questioned, would give the germ theory of infective disease
as the foundation of the principles of antiseptic surgery,
while, as we have seen, it in reality has no necessary con-
nection with these principles at all. The common argument
brought against the aseptic theory is, ' How is it that after
such an operation as removal of a finger, or excision of the
mamma, not performed aseptically, the patient does not as often
die of infective disease as after amputation of the thigh ? '
Now such a question shows the confusion between the two germ
theories. The real question to put is ' How is it that putrefac-
tion does not occm- in all wounds not treated with aseptic pre-
cautions ? ' This I have already explained in considering the
princijiles of antiseptic surgery, but I have nothing to do, in
looking at these principles, with the former question. In con-
sidering the results, I shall demonstrate that the exclusion of
bacteria from wounds is followed by the avoidance of infective
disease, but I do not care whether any one believes that bacteria
are or are not the cause of the infective disease. All I would
ask is that bacteria be excluded, because they cause fermenta-
tions ; and if this be done, as I shall presently show, the causes
of infective disease will also be excluded. If one prefers to
go out of one's way to suppose that not the bacteria, but some-
thing else, excluded at the same time, are the causes of infec-
tive disease, well and good; it does not matter for the _prmci2)^es
of antiseptic surgery.
There are, however, one or two phases in the history of this
subject to which I must briefly allude.
Firstly, attempts have been made to show that Mr. Tester
has no claim as introducer of aseptic surgery. Such statements
•MO HISTORY OF AXTISEPTIC SURGERY.
rest on niisappreciation of the meaning of tliat term. Most of
these writers look on aseptic surgery, and the treatment of
wounds by carbolic acid as one and the same thing, and then
they point out that Lemaire and others used carbolic acid
before Lister.
The first attempt of this kind was made by Sir James
Simpson, in the 'Lancet' for 1867. He says: * Mr. Lister in
his letter to the ' Lancet,' October 5, states that all his recent
visitors to the Grlasgow Royal Infirmary had viewed his treat-
ment of wounds, abscesses, comjDound fractures, &c., and " not
one," he adds, "had ever expressed the slightest doubt that the
system in question was entirely Qiew . . . ! " While I regret
the strange and almost incomprehensible want of knowledge
with which Mr. Lister charges his professional visitors, I am
fortunately not answerable for it, and if Mr. Lister had taken
the slightest trouble to search English medical literature alone,
he would have easily convinced himself of his own grave error
in this respect.' He then proceeds to point out that carbolic
acid had been extensively used in siu-gical treatment before Mr.
Lister published, and that Lemaire and Declat had also under-
stood the principles on which it acted. Had Sir James Simpson
underlined the word system, and not the words entirely new,
and had he continued the quotation which' runs as follows,
'the novelty, I may remark, being not the surgical use of
carbolic acid (which I have never claimed), but the methods
of its employment with the view of protecting the reparatory
processes from disturbance by external agency,' he could hardly
have fallen into such a gross blunder. I need not waste time
in refuting Sir James Simpson's accusations.
Several similar mistakes have been committed by other
writers ; but the only other one which I need mention, as it is
also the most virulent attack of all, is that by Ignaz Neudorfer
in 1877.' His work is a very strange one indeed. He rejects
the germ theory of putrefaction and supposes that the bodies
which fall into wounds and cause fermentation are not bacteria,
but ferments coming from previously fermenting substances.
St range to say, though holding this view, he rejects also the
Lislerian method, which one would think would be as natural a
' Dili clm'uryiic-hc BduDidUiiiij dcr Wiiudeu, 1877.
NEUDORFER AND BARBELEBEN. 361
sequence of such a view as of the germ theory. He also
attempts to show that Lemaire had anticipated Lister in all
particulars, but his statements rest on the same fallacious
foundation as Sir James Simpson's. He falls into the common
error of supposing that Mr. Lister teaches that catgut becomes
revivified, instead of, as Mr. Lister has shown, being eaten
away and disappearing under the action of the neighbouring
living tissues ; and he is very severe on this subject. In-
deed here his bitterness against Lister and his teaching crops
up in an unwarrantable and most offensive way ; and I will
quote his statement here as an example of Neudorfer's writings.
He says : ' Es ist auch hier, wie bei der Wundbehandlung, nur
die Darstellung Lister's welche ganz einfache und klar zu Tage
liegende Verhaltnisse in ein mysterioses Dunkel hiillt, so wie
das Bestreben Lister's an die Stelle der wissenschaftlichen
Erorterung inspirirte Dogmen als Orakel hinzusetzen, welches
die Fachgenossen blenden soil, die seinen sonstigen Ver-
diensten nicht wenig Abbruch thut.'
Mr. Lister's merit in this respect is well stated by Bardeleben
in his lectures ' Ueber die Theorie der Wunden.' ' He says :
' Lange schon wusste mandass ein Magnet Eisen anzieht, lange
genug auch, dass ein Eisenstab magnetisch wird, wenn durch
einen denselben umkreisenden, aber nicht beriihrenden Draht
ein galvanischer Strom geleitet wird, aber die Anziehimg des
Eisens durch den vermittelst des galvanischen Stromes magnet-
isch gemachten Eisenstab fiir die Telegraphic zu benutzen war
doch eine Entdeckung.' — ' So steht es auch mit dem segcnsrei-
chen P^ortschritte welchen wir Lister zu danken haben. Joseph
leister hat weder die Bakterien entdeckt, noch die Karbolsaure ;
aber er hat mit eisemer Konsequenz die Thatsache dass
Faulniss nicht entsteht ohne Einwirkung von Bakterien, oder
wie, er um botanischen Spitzfindigkeiten zu entgehen, lieber
sagt, von Keimen (und dass solche Keime in der Luft schweben)
er hat diese Thatsache angewandt auf den lebenden und
namentlich auf den verwundeten menschlichen Korper. Und
das Ergebniss dieser Anwendung war audi eine Entdechung,
eine Entdeckung wohl werth den grossten Fortscliritton der
iirzl lichen Kunst augereiht zu werden.'
' Tlic passage would lose by translation.
362 HISTORY OF ANTISEPTIC SURGEIIT.
Another phase in the history of this subject to which we
must allude is the introduction of various modifications.
I have ah'eady described the modifications and improve-
ments introduced by Mr. Lister. I have also mentioned the
newer methods of drainage, more especially the use of ab-
sorbable drains introduced by Mr. Chiene, and carried out by
him liy means of catgut, and by Neuber by decalcified bone
tubes.
Neuber has made several attempts to obtain a dressing
which may be left on for a long time. The advantage of such
a dressing is, of course, evident, more especially in the case of
compound fractures, &c., and in country practice. He uses
bone tubes as drains, and catgut for stitches. The drains
in three or four days bec(Hne soft, and in about ten days have
generally entirely disappeared. Large quantities of gauze
(Kriillgaze) are applied next the wound and fastened with a
gauze bandage. Outside this comes a mass of salicylic wool
soaked in the lotion, also fastened with a gauze bandage, and
then outside this the regular carbolised gauze dressing. The
first dressing is left on in the case of large wounds for about
two days. Then the gauze and the salicylic wool are removed,
the deeper gauze dressing soaked with the lotion, and a fresh
dressing applied. This may be left on for ten days or a fort-
night, provided no discharge appears at the edge. This is one
of many ways in which a similar result may be obtained. Of
late Neuber has treated several cases with one dressing alone.
With the view of cheapening the materials, various modifi-
cations have been introduced : thus Brun's gauze, mentioned
before, and also a gauze introduced by Miinnich are outcomes
of these attempts. MuNNiCH uses glycerine and spirit instead
of paraffin. He also in some cases adds stearin. He uses jute
instead of gauze. This carbolised jute is much chea^^er than
carbolised gauze, and has been extensively introduced. Bar-
deleben has used with great success jute soaked with carbolic
lotion and kept moist by frequent addition of lotion. This is
covered with impermeable tissue.
INIodifications of the method have been made with the view
of applying it in war, and I have described previously the sug-
gestions of i\Ir. Lister and Professor Esmarcii. A paper will also
OBJECTIONS TO THE SPRAY. 363
be found on this subject by Dr. Burchardt in the ' Deutsche
militairarztliche Zeitschrift.'
Various other antiseptics have been introduced as substi-
tutes for carbolic acid. Among these I may mention the use
of salicylic acid by Thiersch. This I have ab-eady described.
Thymol was introduced in 1878 by Dr. Eanke of Halle, and
he speaks very highly of its usefulness. It has, however, been
tried by several surgeons, among others by Mr. Lister, and
has not been found to be a trustworthy antiseptic, (^uite
recently H. P^ischer and Professor Maas have advocated the
use of acetate of alumina. Maas uses a 2*5 p. c. spray, and
after applying protective to the wound, he covers it with com-
presses soaked in this solution, and covered with an imper-
meable tissue. He says that the cases follow an aseptic
course, and that, as the antiseptic causes no irritation, the dis-
charge is very slight and the dressings only require to be
changed at rare intervals.
Then of late objections have been made to the necessity
for the spray in aseptic work, and Trendelenburg ^ has recently
published a paper giving the results of some operations per-
formed without the spray. Indeed for four years he has per-
formed all operations strictly aseptically, but in none has he
used a spray. The mode in which this has been carried out is
that indicated before. During and after the operation the
wound is washed out with carbolic lotion and, while the wound
contains this lotion, it is closed. During the changing of the
dressing Trendelenburg adopts Mr. Lister's former method of
allowing fluid to flow more or less constantly over the wound,
and more especially over the orifice of the drainage tube. I
shall discuss this question at a later period.
Some years ago Mr. Callender published results obtained
by a slight modification of Mr. Lister's method, or rather by the
use of jNIr. Lister's carbolic oil dressings. I shall also allude to
these later.
With regard to these attempts, we have already seen that
the spray is the least essential detail of the system ; and I have
described how its use may be done away with with safety. And
this brings me to the last point in connection with the history of
' Ari-Jiir fill' KHnixchf (liiruiujic.
304 HISTORY OF ANTISEPTIC SURGERY.
this subject, viz. : that the method has been objected to on
various grounds, but chiefly because those who have failed in
their attempts have looked on the spray as the essential element,
and on aseptic surgery as the performance of operations or
dressings in a spray of carbolic acid. There cannot be a more
fatal error than this, for the spray is in the great majority of
cases merely a convenience, and not a necessity, and those who
look on it as a necessity are apt to forget the really essential
details, and to trust too much to the spray. I say it is not
essential, for if the wound be easily accessible, and be thoroughly
washed out during and after the operation, the great probability
is that an aseptic result will be obtained. Only it must be
remembered that if the spray is not used, this washing out
nmst not be neglected. But to deluge the wound with carbolic
lotion is an undesirable thing ; and it is for this reason, and also
because the feeling of certainty as to the result must be greater
when the spray is used than when it is not, that I would advo-
cate its continuance.
Other surgeons look on the gauze as an essential element,
and that this is equally an error is evident from a consideration
of Mr. Lister's earlier methods, and also from the results at
present obtained by the use of other materials. One surgeon
has indeed gone so far as to use the term ' spray and gauze
method ' as synonymous with Listerian or aseptic surgery ; in
other words, to define aseptic surgery by two of its least or even
non-essential elements. Aseptic surgery is not treatment by
spray, nor by gauze, nor by spray and gauze, nor by carbolic
acid, but is any method of treatment whicli aims at and
succeeds in excluding the causes of fermentations from
wounds.
365
CHAPTER XVII.
RESULTS OF ANTISEPTIC SURGERY.
Chief points for consideration. How far do the various metliods prevent
fermentations in wounds ? How to ascertain tlie true value of any individual
method. The value of the various methods in guarding against infective
disease : meaning of the term ' infective disease.' Relations of aseptic
surgery to infective disease. Mr. Lister's results in Glasgnw, The recent
Glasgow statistics. Mr. Lister's results in Ediniurgh ; results in septic and
aseptic eases — Mr. Sjjences practice — 3tr. Syme's results — Mr. Lister's re-
sults at King's College Hospital : — Volhnami — N^usshaum — Socin — iSaxtorjj/i
— Esmarch — Hueter — Czerny — Lucas- C/iainpinnuiire — Gros.'< — Lcticvant
— Panas — Schede — Meylwr — Spencer Wells^ Keith — Thornton. Thiersch's
results with salicylic acid. Thymol. The relations of other forms of
Antiseptic Surgery to these diseases — Treatment hy Antiseptics— Beyher —
lAster — Nelaton — Hutchinson. Occlusion — Jules Guenn. — Alphonse Guenn.
Treatment hy irrigation and water bath — Langenbeck — Valette. Open
Met/iod — BaHscher and Vezin — Burow — Kronlein. Results where no
antiseptic measures were adopted — Billroth — Malgaigne — Paul — Holmes
— Erichsen. Results of cleanliness — Savory — 3Ic Vail — Bardenheuer.
In looking at the results of the various methods of treatment,
the following are the chief points which present themselves for
consideration.
1. Results of the various methods as to saving life
{a) by preventing infective disease.
(6) by preventing profuse suppurations and con8e(|uent
exhaustion,
(c) in other ways, such as by rendering operations on weak
or diseased individuals possible, or by enabling the
surgeon to undertake with safety by one method opera-
tions which by other methods would be unjustifiable.
2. Results according as one or other metliod enables t.he
surgeon to render the patient a more useful member of society.
300 JiESUZrS OF ANTISEPTIC SURGERY.
Here I shall have chiefly to consider the bearing of the various
methods on conservative surgery.
3. Method of healing in various cases, and also the behaviour
of sloughs, ligatures, blood clots, &c.
4. The bearing of the various methods on constitutional
disturbance after operations or wounds.
5. Discussion of the objections against the various methods,
and other points.
Before entering on these questions, I must say a few words
as to how far these methods answer the purpose of preventing
fermentations in wounds.
The aseptic method, when properly carried out, does this
completely. There is no putrefaction, and no other kind of fer-
mentation ; and, as I have shown, organisms can be entirely ex-
cluded if it be wished. No doubt in ordinary practice one form
of organism does sometimes get in, but this is only generally
towards the end of the case, and it does not cause putrefac-
tion, while the products of its growth seem to be but little
irritating.
Treatment by antiseptics does not prevent fermentations or
the entrance of organisms, unless, indeed, it is so thorough as to
render the wound aseptic. The specimens of bacteria which
are figured on Plate I. were taken from wounds treated with
antiseptics. Although, however, fermentations are not alto-
gether prevented, yet from the frequent removal of the organ-
isms and their destruction by the antisei)tics employed, fer-
mentation does not, as a rule, occur to any great extent.
The open method hinders the putrefactive fermentation,
more especially because the discharge flows rapidly away and
also because it becomes too concentrated and too freely ad-
mixed with oxygen. Nevertheless, w^henever the discharges
are retained, they undergo fermentation, showing that the
causes of fermentation are constantly present.
Treatment l)y irrigation or by water bath is more effectual
than the open method, because the discharge is removed still
more rapidly and thoroughly ; but, nevertheless, unless a
sufficiently strong antiseptic solution be emY)loyed, the causes
of fermentation are always present in the wound, and may act
if thti-y have opportunity.
MODE OF TESTING THE METHODS. 367
The various methods of occlusion are the most imperfect of
all, and I have already referred to the stench and the state
of the pus in wounds treated by Alphonse Guerin's cotton-wool
method.
In determining whether any instrument or any method is
safe and suitable for use in the ordinary circumstances in which
it will be employed, one does not simply content oneself with
using it under such circumstances, but various tests are applied
to it, Le. it is subjected to trials greater than those which it
will have to undergo in every-day work. A gunmaker is not
satisfied with a gun if it does not bm-st with an ordinary
charge ; he overcharges it, and if it withstands this test, he very
properly concludes that it will be efficient and safe as ordinarily
used. A boilermaker does not send out a boiler as trustworthy
till he has subjected it to pressure such as it may never have
to bear afterwards, but which it might, under rare circumstances,
have to endm'e.
In considering the value of the various methods of wound
treatment as protectors against death, we must in like manner
consider how they behave in the very worst circumstances, in
circumstances in which they may never or only very rarel}' have
to be employed ; for a method which is effectual under unfavour-
able circumstances ought to be employed in all, unless there is
some special and valid objection to its use. The tests, there-
fore, which I shall apply to these methods (so far as I can
find the reiiuisite material) with the view of determining how
far one or other may be depeuded on as a guard against the
more serious dangers of o^jerations, are their behaviour in
unfavourable hygienic conditions, or indeed, in infected atmo-
spheres, and to what extent they protect patients after opera-
tions which are peculiarly liable to be followed by serious con-
sequences.
Firstly, then, with regard to Infective DUease. Under this
heading I include Pyaemia, Septicaemia, Erysipelas and Hospital
Gangrene. Closely allied to these is Septic Intoxication, which
I would call, after Matthews Duncan, Saprcemia. For though
this is merely the result of a chemical poison, it is a disease
which is dependent for its occurrence on fermentation in
368 RESULTS OF AXTISErTIC SURGERY.
wounds, and it must, therefore, l^e included in this grou)). T
do not add Tetanus, because I do not think that there is suf-
ficient evidence as yet to justify us in classing it among septic
diseases, though several eminent surgeons, more especially in
Germany, hold that view.
I shall first consider
The Relations of Aseptic Surgery to these Diseases.
The first record which I can find — and it is a very striking
one — is a paper published by Mr. Lister himself, in which he
gives his results in Gflasgow up to the time when he went to
Edinburgh. This will be found in the ' Lancet ' for 1870. In
this paper he describes the progress of his cases and the state
of his wards in the Glasgow Infirmary before and after the in-
troduction of aseptic surgery. He tells us that on account of
the constant presence of infective diseases in that hospital when
he went to Glasgow, he had to diminish the number of beds in
each ward, and he states that infective disease was so com-
mon, that whenever a case of compound fracture was admitted
into his wards, he at once ordered the internal administration
of sulphites, which were at that time much used as prophylactics
against these diseases. In some of the other wards these
diseases became at times so prevalent that the wards had to be
closed.
Mr. Lister gives the following statistical table of his results
in amputation cases before and after the introduction of aseptic
surgery. The statistics before the introduction of that method
include the results of two years' practice (1864 and 1866, the
report for 1865 being imperfect). During that time the
following amputations were })erformed, with the following
results: —
Cases Deaths
Through the shoulder-joint :5 2
,, upper arm ...... 8 2
„ elbow-joint ...... 1 1
„ forearm ....... .5 1
„ hip 5 4
„ thigh 10 3
„ knee-joint ...... 3 1
„ ankle 5 2
Total ... 35 16
A morlality of l.rT p. c.
MR. LISTERS GLASGOW STATISTICS.
8G9
The causes of death are not definitely stated, but ahnost all
were due to infective disease. Thus of the six deaths following
amputations of the upper extremity, four were due to pysemia
and one to hospital gangrene.
In contrast to this, Mr. Lister mentions the results obtained
during the aseptic period (1867, 1868, 1869). The following
were the amputations performed : —
Shoulder-joint
Uijper-arra
Forearm .
Hip-joint .
Thigh
Knee
Ankle
Total
A mortality of 15 p. c.
Cases
8
3
6
2
•i
13
9
40
The causes of death in all the cases is not given. In two —
an amputation at the hip-joint and a double amputation at the
knee — death occurred from shock and loss of blood. Mr. Lister
also states that two of the deaths resulted from pyaemia, but in
one of these the pyyemia existed before the operation (amputa-
tion of the forearm), and in only one case (an amputation at the
knee) did pyaemia arise after the operation. But further, these
were the only cases of pyaemia which occurred in Mr. Lister's
hospital practice during these three years, and that in spite of
the former frequency of the disease. And among the other
cases treated during this time were twenty-two comjjound
fractures, and several compound dislocations.
During the same period only one case of erysipelas occurred,
but it did not prove fatal.
Hospital gangrene attacked one or two wounds, but it was
of a very mild type ; and Mr. Lister states that during tlie last
year of this period he had no cases of that disease.
Two other points must also be taken into consideration.
Firstly, the annual cleaning of the wards, which had previously
been necessary, was not carried out during those three years.
Secondly, when Mr. Lister remarked the great improvement In
the healthiness of his wards, he increased the number of beds
in each.
370 liE^'SUL'ns OF ANTISEri'IC SURGERY.
Here we have a very valuable piece of Statistics ; and it is so
much the more striking as the results were obtained in the
early days of aseptic surgery before any of the recent improve-
ments had been introduced. During a period of three years,
there occurred only two cases of pyaemia, one case of erysipelas
and one or tAvo cases of mild hospital gangrene, and this result
was obtained in unhealthy wards in which these diseases were
previously common, and in wards which, towards the end of the
aseptic period, were in much more unfavourable hygienic con-
ditions than before the commencement of that period. Looking
at only one class of operations, the mortality after amputations
was reduced from 45*7 p.c. to 15 p.c, and that reduction was
in the main or altogether owing to the abolition of infective
disease. I say that these statistics are of the greatest value, and
it is strange that they have been allowed to pass unnoticed by
those who have cried so loudly for statistics ; for they answer
almost all the requirements. They are results obtained by the
same surgeon in the same wards in successive years. And the
result cannot be ascribed to better hygienic conditions ; for, as I
have just pointed out, there was no improvement in the hygienic
arrangements during the aseptic period, in fact, rather the con-
trary, for the annual ward cleaning was done away with, while
an increased number of beds was introduced. Nor can the
results be ascribed, as is so much the fashion in some quarters,
to cleanliness alone, to the cleansing of the instruments after
each dressing, &c.; for long before Mr. Lister had thought of the
aseptic method, he had striven to prevent all such contamina-
tion, being fully impressed with the evils of putrefaction, and
with the necessity of avoiding it, as far as possible. Neverthe-
less, though cleanliness had been tried, it had failed.
While speaking of Glasgow, I may mention here the recent
statistics given by Mr. MacEwen in 1879.' They are merely
nvnnerical, but nevertheless, they are striking, and when con-
sidered along with the other results which will be referred
to presently, they will be seen to be of great value. INIr.
MacEwen, thinking that pure air was of more value than aseptic
treatment, asked the medical Superintendent of the Glasgow
Infirmary to compile comparative statistics of cases treated asep-
' JJritisk Medical Jaiiriinl, 187U.
MR. MAC EWEN'S STATISTICS. 371
tically and of those treated in other ways. To his siu-jjrise, the
facts showed the opposite of what he had expected. Thus, dui'ing
the years 1875, 1876, 1877 and 1878, 1706 cases were treated
strictly aseptically under the care of Dr. Cameron, and of these 50
or 2*93 p.c. died. During the same period, in the same number
of wards, under Dr. Morton's care, 1884 cases were treated not
aseptically, and of these 110 or 5*84 p.c. died, the cases in each
instance being practically of the same character. And not
only was the mortality in the latter case more (it was double)
than in the former for the whole period taken together, but a
similar difference was found when the results of each year were
looked at separately. Thus the percentage mortality during
1875 was,
among aseptic cases
3-29 p. c
,,
„ non-aseptic cases .
7-63 „
1876
,, aseptic cases
3-28 „
„
„ non-a«eptic cases .
f>-itl „
1877
„ asefitic cases ....
3-G8 „
„
„ non-aseptic cases .
5-13 „
1878
„ aseptic cases ....
203 „
)j
„ non-aseptic cases .
396 ,,
As is remarked in a leader in the ' British Medical Journal '
on this subject : ' The result, therefore, proves that, under
antiseptic treatment, the mortality was, under apparently
strictly comparable circumstances, much smaller than under
the ordinary mode. . . . This is a case very much to the point,
and will meet some of the conditions of comparative statistics
rightly insisted on by IMr. Holmes.' Some correspondence
followed between Dr. Cameron, Dr. Morton, and JNIr. ]MacEwen,
after the publication of these results, but the further informa-
tion elicited did not in any way alter the significance of the
facts.
I will now pass on to Mr. Lister's results in the Edinburgh
Infirmary. These have been already published in his speech at
the meeting of the metropolitan branch of the British ]\redical
Association at St. Thomas's Hospital in December, 1879 ; ' and
some further facts were given by Mr. Lister in his reply, in
February 1 880, to Mr. Spence's attack.^ I shall not, therefore,
enter at great length into these general statistics, more espe-
' Sec JMacCormacs Avti-icjitir Siirfierif.
■ BrHuh Mrdiriil Journal, 1880.
37:?
liESULTS OF ANTISEPTIC SURGERY
oially as I intend presently to allude to some of the facts in
detail.
From the end of 1871 to the middle of 1877 — a period of
about five and a half years — Mr. Lister treated 553 eases
aseptically. Of these 2, or '36 per cent., died of blood poison-
ing. During the same period, Mr. Lister treated 292 cases
in other ways, some with antiseptics, some without, and
of these 4, or 1*36 p. c, died of blood poisoning. Now this alone
is a very striking statistical fact, as it shows that the same
surgeon, in the same wards, during the same time, lost four
times as many patients from blood poisoning in cases not
treated aseptically as in those which were treated on strict
aseptic princij)les. And when we look at the nature of the
cases in each instance, this difference will become much more
apparent.
Of the 553 cases treated aseptically, 29 died.
Among these were 80 major amputations, of which 9 died — 6 from
shock within a few hours, 1 from diphtheria in the throat nine
weeks after operation, when the wound was almost enthely healed ; 1
from cerebral hsemorrhage three months after the operation ; and 1
from hsemorrhage into the thigh from a malignant tumour of the femur
thi-ee days after amputation at the shoulder-joint — the amputation
wound was doing well.
The following is a complete table of M
r. Lister's
amputations : —
For disease
Primary
and secondary
to injury
Total
Cases
Deaths
Cases
Deatlis
Cases
Deaths
Hip .
1
1*
2
2#
3
3
Thigh
3
2*
26
If
29
3
Leg .
3
0
5
0
8
0
Ankle
2
0
16
n
18
1
Shoulder
4
1*
]
^
5
2
Upper-arm
3
0
6
0
9
0
Forearm
—
—
8
0
8
0
Total
16
4
64
5
80
9
* Died in a few hours from shock ; f died from diphtheria ; % from cere-
bral luvmoiThage ; § from hemorrhage into the thigh.
There were akso 21 excisioDS of the larger joints performed asep-
MR. LISTERS RESULTS IN EDINBURGH. 373
tically without a death (7 of knee, 2 of shoulder, 10 of elbow, 2 of
wrist).
Thirty-seven excisions of the mamma were perfoi^med aseptically
with two deaths, both from infective disease. One of the deaths was
from septicaemia occurring after the removal of a very large portion
of skin and of the whole contents of the axilla. Everything went on
perfectly till the tenth day, when a mistake was committed in the
dressing ; putrefaction occurred, and septicfemia commenced. On
post-mortem examination no abscesses or infarcts or other marked
appearances wei-e found. The other patient died of erysipelas.
Among these 37 cases there were 24 in which not only the mamma,
but also the fat and glands from the axilla were removed.
There were 27 operations for un-united, or badly united, fractures
without a death. These consisted of 8 operations on the femur, 9 on
the bones of the leg, 4 on the humerus, 5 on the bones of the fore-
arm, and 1 on the clavicle (removal of a projecting splinter of bone
in a case of simple fracture, thus converting the case into one of
compound fracture).
There were 14 operations on healthy joints, in which the joints
were opened and kept open for some days by means of a drainage
tube. No death.
In 11 cases incisions were made into diseased joints in which
suppuration had not yet occurred. No death. These were cases of
gelatinous disease.
There were 39 cases in which abscesses of joints were opened and
a drainage tube inserted, none of the diseased parts {bone, synovial
membrane, &c.), being removed. Of these, 2 died, both from tuber-
cular meningitis confirmed on post-mortem examination.
An incision was made and a drainage tube inserted in 2 cases of
synovitis of the knee-joint. No death.
There were 4 cases in which operations were performed to relieve
old standing dislocations. In some of these the bones were simply
replaced. In one case it was necessary to remove portions of the
bone before the surfiices of the joint couhl be brought into apposition.
No death.
In 3 cases the femur was divided for knock -knee. No death.
In 7 cases of ostitis a groove was dug in the bone by a gouge and
hammer. No death.
There were 7 cases of ligature of the large arteries in their con-
tinuity, with 1 death. The fatal case is not entered in the note-books,
but I remember its occurrence. During attempts to I'educe a disloca-
tion of the shoulder-joint of seven weeks' standing, the axillary artery
;]74 llESULTS OF ANTISEPTIC SURGERY.
was toi'ii and haemorrhage occurred into the axilla. Mr. Lister at once
cut down and ligatured the artery, but the patient died the same night
from exhaustion, owing to the loss of a large quantity of blood.
There were 2 cases of excision of the thyroid gland. No death.
There were 4 cases of excision of the testicle. No death.
There were 9 cases of strangulated hernia, with 3 deaths. The
gut was gangrenous in all the fatal cases.
There were 30 cases of abscess (psoas or lumbar) connected with
disease of the spine. Of these 4 died — 2 from phthisis, 1 from ex-
haustion, and in one case the lumbar abscess was almost absolutely
healed when a little glandular abscess formed in the neck. This was
opened without aseptic precautions, and the wound was attacked
with erysipelas, of which the patient died. Though this was an
aseptic case, yet the erysipelas did not attack a wound treated
aseptically, and therefore the death from infective disease is in-
cluded among the cases not treated aseptically, and not among the
aseptic ones.
There were 9 1 cases of acute or chronic abscesses. These included
a great variety of abscesses, but they were all more or less extensive.
There were 2 deaths ; one death occurred in a case of peri-renal
abscess. The patient was in a very low state when operated on, had
diarrhoea, &c., and he sank in ten days. On post-mortem examination
the typical scrofulous kidney was found. The other death occui-red
in a case of abscess in the right lumbar region, but in which there
was no disease of the spine. The abscess was opened on May 20,
1873, and went on veiy well till July. There was then only a small
sinus, and the patient was })ermitted to get up. During autumn the
discharge was allowed to putrefy, and it afterwards increased rapidly
in amount and became purulent. For some days before her death, on
November 15th, the patient had very severe pain in the right iliac
region and the right limb, and following this the leg and foot became
gangrenous (phlebitis ?).
There were five cases of empyema. No death.
There were eight cases of chronic bursitis, in which incisions were
made and drainage tubes inserted. No bad result.
There were twelve cases of removal of exostoses without a death.
There were forty cases of removal of large tumoui-s from various
regions. No death. (There were also a number of cases in which
smalUsh tumours, fatty or otherwise, were removed. These are not
included among the forty.)
There were three cases of suprapubic lithotomy, with two deaths. In
one fatal case, an adult male, the peritoneum was intentionally oj^ened
below the umbilicus, the bladder incised through its peritoneal coat.
MR. LISTERS RESULTS IN EDINBURGH. ;37o
and the stone extracted. The wonnd in the bladder was then stitched
up, as was also the wound in the' abdominal wall. The patient was
doing well till the second morning (about forty hours) after the opera-
tion, when he got out of bed, or was made to get up. As a result of
this exertion the intestines protruded between the stitches. Tbey
were returned as soon as the accident was discovered, but the patient
died of shock on the same day. In the other fatal case^ a little boy,
the peritoneum was also opened, but the stone was not removed. The
child cried incessantly after the operation, and in spite of the close
stitching of the wound in the abdominal wall, the intestines escaped
between the stitches. The patient died on the following day from
shock.
There were three cases of spina bifida, into which minute drains, in
two cases horse-hair (two or three threads), and in one a drainage tube,
were introduced. The patients apparently died as the result of the con-
stant draining away of the cerebro-spinal fluid, although as soon as bad
symptoms were evident, the drains wei-e withdrawn. In two cases no
macroscopical appearances were found to account for death. (I do not
know what the microscopical appearances of the cord may have been.)
In one case the sac was congested, and contained a little turbid tiuid,
but there was no violent inflammation, and the little which was pre-
sent did not apparently spread up the canal. In fact, the appearances
found could not explain the fatal result in any of the cases, and there-
fore it is possible that the disturbance due to the constant draining
away of the cerebro-spinal fluid had something to do with death.
The first two cases died in two and nine days respectively. The last
died in five days.
One case of chronic hydrocephalus was treated in this way (by
drainage) and died in six days. There was no trace whatever of in-
flammation. The ventricles were extremely distended, containing
forty-two ounces of clear cerebro-spinal fluid. Apparently the fatal
result was due to the same cause as in the former instances, viz., the
disturbance consequent on the constant draining away of the cerebro-
spinal fluid.
These are the most impoii:ant of the 553 eases. (Although
there were only two deaths from infective disease after aseptic
operations, and although that fact was all that was necessary for
our present purpose, I have thought it well to mention all the
causes of death, and to indicate the sort of cases treated.)
The 292 cases not treated aseptically contained a very much
larger proportion of trivial operations, such as removal of
y70 ItESULTS OF ANTISEPTIC SURQEIiY.
necrosed bone, Hstula in ano, ha'morrhoids, &c. There were
ten deaths, of which two were from pygemia, one from septic-
aemia, one from erysipelas, and six from exhaustion (?).
The cases of pyaemia occun'ed, one after a plastic operation on the
nose, and one after amputation of the penis. The case of septicemia
occurred after excision of the tongue. The case of erysipelas occurred
after the opening of a small abscess in the neck without aseptic pre-
cautions; this case is mentioned among the psoas abscesses (p. 373).
Onecaseof excision of the hip-joint (a^t. seventeen) died twenty- nine days
aftei' the operation, apparently of exhaustion from the profuse discharge.
One case of excision of the mamma (set. sixty-three), where putrid sinuses
were present before the opei'ation, died in three days of exhaustion. ( May
not the fatal result in this case have been due to saprsemia ?) One case of
excision of the upper jaw (set. sixty-three), died twenty- three days later,
apparently of exhaustion ; there were no marked symptoms during life,
and no post-mortem appearances ; there were haemorrhages on various
occasions after the operation. One case of excision of the tongue
(set. seventy-five) died in ten days without any special symptoms,
apparently of exhaustion; no morbid appearances were found on
post-mortem examination. One case in which the floor of the mouth
was removed for malignant disease (an old woman) died apparently
of exhaustion. One case of old standing, necrosis of the ilium (ajt.
twenty), died twenty-three days after an attempt to remove the dead
bone. He is also said to have died of exhaustion, but there is no
record of the post-mortem examination, and he had coffee-ground vomit-
ing during the forty-eight hours preceding death. (Several of these
cases of exhaustion were probably cases of sapraamia or septicaemia.)
If we compare the causes of death in the two instances and
the nature of the operations, the case in favour of the asej)tic
method becomes much stronger than if we simply compare the
deaths from infective disease. lu the septic cases the patients
either died of septic disease or of exhaustion, the result of pro-
fuse suppuration, again the result of putrefaction. If we con-
sider the aseptic cases, on the other hand, we get a very
different result. Thus, among the deaths after amputation
there was not a single case where any method of treatment
applied to the wound could possibly have saved the patient.
The two deaths from tubercular meningitis, the three cases of
hernia in which the gut was gangrenous, and the two cases of
phthisis were all independent of the tieafment of the wound.
ItESULTS OF TllEATMEXr WITH ANTISEPTICS. ;J77
The case of peri-renal abscess was also hopeless, and so also,
possibly, the case of abscess in the loin where gangrene of the
foot occurred. In the case of exhaustion after psoas abscess
the disease was extremely extensive. But suppose we include
this case, the two cases of infective disease, the three cases of
spina bifida, the case of hydrocephalus, and the two cases of
suprapubic lithotomy, we have only nine instances of what we
may term preventible deaths. In the last six cases, however,
it was rather to the direct surgical interference than to any-
thing in the after-progress of the wound, looked at from our
present point of view, that the deaths must be attributed ; and
here, of course, we are not considering the former point.
Leaving then out of view the question of the surgical inter-
ference, there are only three cases among these, which can be
considered in connection with the method of wound treatment
alone. Indeed, I doubt very much if it is fair to include the
case of exhaustion after psoas abscess, for the disease was of
such a natmre, so very extensive, as to render it doubtful
whether recovery was possible under any circumstances.'
On the other hand, among the fatal septic cases, there were
none independent of the after-progress of the operation wound,
unless indeed we exclude the case of necrosis of the ilium
in which probably waxy degeneration of the internal organs
had occurred extensively before the operation. This leaves 9
out of 292 septic cases, of which a large proportion were trivial
operations in which death occurred on account of the course
which the wound followed, while in the former instance, in
the 553 aseptic cases, a very small proportion of which were
trivial operations, there were only, at the most, three such in-
stances.
During this same period there were treated aseptically in
hospital seventy-two cases of injury (wounds, compound
fractures, and wounds of joints), of which four died.
Three of these deaths occurred in cases of compound fracture
treated conservatively, and in all death took place within 48 hours.
The other death occurred in a case in which the attempt to eradicate
putrefaction was unsuccessful, and where the patient is said to have
died of bronchitis and caidiac disease.
' fciee the list of psoas abscesses, No. 21, Ciiapler XX.
378 ItESULTS OF AXTISEPTIC SURGERY.
Here again, there is only one ease of possibly preventible
death, and that in a septic ease. Among those which were
rendered aseptic no death occiuTed which was preventible by
any known method of wound treatment.
We have fortunately the opportunity of comparing these
results with those obtained by another surgeon — ]Mr. Spence — in
the same hospital during the same time, by the use of methods
of treatment which were not aseptic but which consisted
sometimes in the application of water dressing, sometimes of
boracic lint, and in some cases no dressing was used. I cannot
give a name to the method of treatment. It was a mixture of
principles, in fact a sort of mongrel method. There were certain
differences in the hygienic conditions which will be presently
alluded to, but these were all more favourable to ]\ir. Spence.
Mr. Sj)ence's report extends from October 1872 to April
1878 with the exception of the winter session 1874-75.' I
regret that I cannot find any report for this session, as dming
it there was a virulent epidemic of erysipelas in Edinburgh,
and it would have been interesting to know how Mr. Spence's
cases progressed during that time. Taking, however, the
period so far as it is given, but always remembering that
a very testing winter included in Mr. Lister's results is not
present here, we find that dming this time 328 more or
less severe operations were performed with fifty-eight deaths,
and that three cases of compound fracture were treated con-^
servatively with one death. What proportion of these deaths
were due to infective disease, we shall, I suppose, never know.
In sixteen out of the fifty-eight cases the cause of death is not
stated at all ; five died within thirty hours, and may therefore
be left out of consideration ; while in eight the fatal result is
directly assigned to septic poisoning. In twenty-nine of the
cases no distinct causes of death are given, though such state-
ments as the existence of irritative fever, unhealthy action in
the wound, uncontrollable oozing of blood, &c., lead us to sus-
pect that infective disease was also at work in these instances.
These results form a marked contrast to Mr. Lister's.
' See 3Icdical Times and Gazette, March 13, 1875 ; the same journal for
October 28, 1876 ; and the November and December numbers of the Edinburgh
Medical Juurnaliov 1879.
3fR. SPUNCE^'S RESULTS.
37U
Here we have a percentage mortality of nearly eighteen p.c. as
compared with Mr. Lister's percentage mortality in aseptic
cases of nearly five p.c. i.e. a mortality in septic cases 3'7 times
greater than in aseptic ones. And further the cases of death
which are distinctly stated by Mr. Spence as having been due
to septic diseases were eight in number or 2*4 p.c, that is to
say, eight times more than the mortality from similar causes in
Mr. Lister's aseptic practice. And, as I have just indicated, the
mortality from these causes in Mr. Spence's practice was
probably very much greater ; and this difference is not due to
greater severity of the operations in INIr. Spence's j)i'actice, as
we shall see from the following statement of the nature of his
cases.
During this pei'iod Mr. Spence performed 97 amputations, of
which 25, or 25-7 per cent., died. (Compare this with Mr. Lister's
mortality of 11 "25 per cent, after amputations performed on aseptic
principles.)
The following table gives Mr. Spence's results in major amputa-
tions : —
Secoudary to
Prill
ary
iiijury and
for disease
Total
Cases
Deaths
CaKBs
Deatlis
Cases
Deaths
Hip. ....
0
0
3
1
3
1
Thigh .
5
.3
26
G
31
i»
Knee-joint
1
0
0
0
1
0
Leg.
4
0
9
2
13
2
Ankle
1
0
24
2
2.5
2
Shoulder .
1
1
3
1
4
2
Arm
2
1
7
2
9
3
Fore-arm .
2
2
2
2
4 4
Tot
al
IG
7
74
If.
00 23
From this table I have excluded 6 partial amputations of the
foot, with 2 deaths, and 1 partial amputation of the hand. These
are included by Mr. Spence among his major amputations, but I
have already excluded such operations from Mr. Lister's list.
As to the causes of death in these cases, one patient on whom am-
putation at the hip-joint was performed rallied after the operation,
but .sank suddenly next day. One case of primary amputation of the
thigh died from sliock, and 1 from pyaemia : 1 amputation of the
380 RESULTS OF ANTISEPTIC SURGEItY.
thigh for disease died of tubercuhir meningitis ; 1 died 5 days after
the operation, and it is stated that he had dian-hoea ; in 1 case oozing
of blood came on 2 or 3 days after the operation. One secondary
amputation at the ankle-joint died from septic poisoning, ana 1 had
diarrhcea and tabes mesenterica. One fatal case of amputation at the
shoulder-joint had repeated hfemorrhages from the wound. One case
of amputation through the upper arm died 2 days after the operation,
having had continuous oozing of blood ; in 1 case general oozing
began on the 6th day but was arrested by styptics, and the patient
died on the 7th day. One primary amputation of the fore-arm died
from pneumonia, and 1 had fever, traumatic delirium, diarrhcea and
vomiting, and died on the 10th day; 1 died from erysipelas and 1
from pleurisy and pneumonia. The causes of death in the other
fatal cases (8 in number) are not referred to.
Among the other cases treated were 57 excisions of various joints,
of which .7 died ; 34 excisions of the mamma with 2 deaths ; 10 cases
of lithotomy with 1 death ; 44 cases of removal of tumours with 8
deaths ; 9 complete or partial excisions of the tongue, 4 deaths ;
4 cases of tracheotomy, no death ; 31 operations for necrosis, no
death ; 1 operation for badly-united fracture of the femur, no
death ; several miscellaneous severe operations, 6 deaths ; 3 excisions
of the lower jaw, no death ; 3 castrations, no death ; 2 cases of
trephining.
On comparing these cases with Mr. Lister's we find that
the operations were not more severe, and yet the mortality was
nearly four times as great.
Mr. Spence had thirty-one amputations of the thigh against
Mr. Lister's twenty-nine, but nine deaths against three.
The total number of cases in which bones were operated on,
such as for ununited fractures, excisions, &c. was greater in
Mr. Lister's practice, and yet he had no death as compared
with Mr. Spence's seven fatal cases. This difference is the more
remarkable when it is remembered that many of Mr. Lister's
operations were performed on healthy bones, while the greater
number of Mr. Spence's were performed on diseased bones. It
is less dangerous to operate on the extremity of a bone than on
the dense shaft, especially where the medullary cavity is
opened. And the dangers of the operation are diminished if
the bone be previously the seat of chronic inflammation, for a
chronically inflamed bone is well advanced on the road to
MR. SPENCE'S RESULTS. 381
granulatiou, and granulation is, therefore, much sooner com-
plete after the operation than in the case of healthy bone. In
other words, the time during which there is risk of absorption
from the wound is shorter in the case of chronically inflamed
bone than in the case of healthy bone, while the risk is from
the first less, because in the diseased bone a partial barrier is
present from the beginning.
Then, among ]\Ir. Spence's cases there is not a single in-
stance of simple incision and insertion of a drainage tube into
a healthy joint, a diseased joint or a suppm-ating joint, while
Mr. Lister had seventy-six of these cases.
Then, also, Mr. Spence does not seem to have treated a
single case of psoas or lumbar abscess.
Thus, however we look at the matter, the contrast between
septic and aseptic surgery is very markedly in favom* of the
latter. This is well seen in Mr. Lister's own hands, in which
the results of cases treated aseptically were much better than
of those treated in other ways, these results being obtained by
the same surgeon, in the same wards, and during the same
time. The same contrast in favour of aseptic surgery is shown
by the results obtained by another surgeon, in the same hospital,
during the same time, and under circumstances in every way
more favourable, both as regards the severity of the cases and
the hygienic conditions under which the patients were jjlaced.
With regard to the latter point, it must be noted that jNlr.
Spence's wards were well ventilated and at the top of the build-
ing ; Mr. Lister's wards were at the lower part of the building,
some on the basement floor. Mr. Spence did not overcrowd
his wards ; Mr. Lister had as a rule nearly seventy patients in
wards containing fifty beds, and these beds were more closely
packed than Mr. Spence's. (The way in which this was
managed was, that those adult patients who were well enouoh
to be up during the day, slept on mattresses placed in various
parts of the ward at night, while children were placed two, three
and sometimes even four in a bed.) Then, lastly, Mr. Spence's
wards were thoroughly cleaned out once a year ; Mr. Lister's
wards, on the other hand, did not, at his own request, undergo
this annual process.
That the wards in which Mr. Lister worked were unhealthy
'S62 RESULTS OF AXTISEPTIC SUIiGERY.
wards, is shown by the results obtained by jMr. Syme during
his last four years. Of amputation cases (120 in number) he lost
twenty-five from infective diseases alone, while Eeyher,^ who pub-
lished these comparative statistics, states that Mr. Lister, up till
the end of 1873, in 123 amputations, had not lost one from infec-
tive disease, unless indeed we include a case of tetanus as such.
These statistical facts fulfil the conditions required by Mr.
Holmes in his recent utterances, and they are therefore
deserving of careful consideration.
I shall now pass on to consider JMr. Lister's results in King's
College Hospital, from November 1877 till November 1880.
During this period there were 207 operations performed asepti-
cally, of which fourteen died. All of the operations were more
or less serious, and the following is a sample of them, with the
causes of death in the fourteen cases.
Thei'e were 3 amputations at the hip-joint for disease, with 1
death. This case died from shock half an-hoiir after the operation.
There were 4 amputations of the thigh for disease, of which 3
died : — 1 got suppression of uriiie on the second day and died ; his
kidneys were extremel}'" fatty, and the fact that he had marked albu-
minuria had been overlooked before the operation. One case died of
pneumonia ; he had a slight cold before the operation, caiight from
draughts in the ward ; afterwards he got pneumonia, which was
apparently distinctly traceable to exposure during the energetic ven-
tilation of the wards in the intense cold of winter. (Such ventila-
tion is, I need hardly say, unnecessary in wards where aseptic treatment
is carried out ; the comfort of the patients is the point to be attended
to rather than the constant flow of a current of aii- through the
wards.) A post-mortem examination was not allowed in this case
The third case was one of spontaneous gangrene of the foot and leg,
where amputation of tlie thigh was iDerformed. Gangrene recurred,
and the patient died on the 4th day after the operation.
There were 2 amputations of the foi'e-arm. No death.
There were 16 excisions of the mamma and axillary glands, with
2 deaths. Both opei-ations were very extensive, and both patients
died from shock within 3G hours.
There were 13 incisions into healthy joints, no death ; 5 in-
cisions into joints affected with synovial degeneration, but without
buppuration, no death ; 3 incisions into joints affected with synovitis,
' Archil- fur KJin. Chirurfiie, Bd. xvii. p. 4',)!i.
J/7i'. LISTER'S RESULTS IX LONLOy. 583
no death ; 9 incisions into supj)urating joints, 2 deaths, one of which
was due to tubercular meningitis, confirmed on post-mortem examin-
ation, and 1 occurred in a child admitted with acute abscesses in
various joints, in fact with pypemia after scarlet fever ; he died 2
days after admission.
There were 31 operations on healthy bones for deformities,
ununited fracture, (tc. No death.
There were 8 abscesses (lumbar or psoas) connected with disease
of the spine. One death. This case putrefied, and the patient was
sent home, but died at home from exhaustion a few weeks later.
Though not a death in hospital, it is a death in a case treated at the
first aseptically, and I have therefore included it. Putrefaction occuri^ed
owing to the circumstance that the patient suffered from carbolic
acid poisoning, and hence the dressings were left on longer than
usual, and thymol dressings were ultimately substituted for the
carbolic gauze, with the result that the discharge putrefied.
There were 4 cases of strangulated hernia with 3 deaths. In one
fatal case the bowel was gangrenous ; the gangrenous portion was cut
away and the divided ends of the gut vmited by suture ; the patient,
who was collapsed at the time of the operation, died in 2 or 3 hours.
In one case the patient, an old woman, was in a state of collapse at the
time of the operation and never recovered, dying within 24 hovu-s. In
one case the gut, which was in a suspicious state at the time of the
operation, gave way 60 hours later, and its contents escaped into the
peritoneal cavity. The patient died in a few hours.
There were 3 opei-ations for radical cure of hernia, in which the
greater part of the sac was cut away and the mai-gins stitched with
cat-gut. No death.
There were 3 cases of acute necrosis where incisions wei-e made
down to the bone and drainage tubes inserted ; the bones were not
resected, as Mr. Spence recommends, such a procedure being un-
necessary with aseptic management. One of these cases, a child,
which was appai-ently in a septicsemic state before the opei-ation,
died 5 days afterwards.
There were 23 large abscesses, among whicli were 6 iliac
abscesses, 3 gluteal, 1 pelvic, 2 mammary, 2 in calf, 2 in thigh, 1
case in which there were 7 chronic abscesses, 2 cases of suppuration
of bruises ; all of them extensive. No death. Two cases of empyema.
No death.
There were 2 cysts of the thyroid gland, which were opened and
drained ; no death. Three excisions of the thyroid gland ; one
death. In the fatal case tlu; tumour was adherent to tlie trachea.
084 RESULTS OF ANTISEPTIC SURGERY.
which had become thinned by the pressure, and in removing the
tumour the thin membrane gave way. Thus the case was no longer
an aseptic one. The puti-id matters passed down the trachea,
and gave rise to inflammation of the bronchi. The difficulty in
breathing was not relieved by the operation. The patient died 16
days after the operation. At the post-mortem examination an open-
ing was found in the trachea large enough to admit the tip of the
little finger, and communicating with the wound. The lungs were
(Edematous, and a small quantity of pus could be squeezed from
various parts, but there were no abscesses or infarcts. A lai-ge
tumour was found in the thorax surrounding the trachea, and partly
also the arch of the aorta. There were no other post-mortem
appearances. This is, of course, a septic case, and ought not to be
included in this list, but I insert it, as the operation was undertaken
with the intention of performing it aseptically, and as it is such a
marked contrast to the others.
Then there were a number of single operations, which it would be
too tedious to enumerate, such as 2 cases of nerve stretching, 2 cas-
trations, 1 operation for aneurismal varix, 5 varicoceles (veins tied),
removal of tumours of various kinds, &c.
If now we look at the causes of death we find that several
were unconnected with the treatment of the wound. Thus the
case of shock after amputation at the hip-joint and the two
fatal cases after excision of the mamma are quite irrelevant.
So also are the three deaths after strangulated hernia, the
death from tubercular meningitis, and the death of the little
boy admitted with pyaemia.
How are we to look at the cases of death from suppression
of urine, after acute necrosis, and after recurrence of gangrene ?
Could these have been prevented by any method of treatment ?
The thyroid case was a septic one.
This leaves us with two cases to consider: the case of
pneumonia, which I myself saw, and which I, as well as others
who know the facts, firmly believe to have been caused by im-
prudent ventilation ; and the fatal case of psoas abscess, which
undoubtedly ought to have been avoided, and would in all
probability have been so, had not the patient been so sen-
sitive to the effects of carbolic acid.
During these eight years, three wounds of healthy joints
and fourteen compound fractures were treated, with one death.
VOLE MANN'S RESULTS. 386
This death occurred in a case of compound fracture of the
skull, the patient being comatose when admitted ; trephining
was performed, but he died within twenty-four hours. There
were also a number of more or less severe wounds under treat-
ment at the same time.
Looking then at the whole results attained by ]Mr. Lister,
we must, I think, come to the conclusion that he is correct in
stating, from his own experience, that infective disease is
abolished by aseptic treatment, so that, if an operation can
be performed aseptically the risk of infective disease may
practically be left out of consideration in deciding on the ad-
visability of the operation. This view has been amply borne
out, as I have shown, by thu-teen years' constant work in three
different hospitals — none of them particularly noted for health-
iness.
One of the first surgeons to take up the aseptic method
thoroughly, was Professor Yolkmann of Halle ; and he has con-
tributed some remarkable testimony to the efficacy of the
system. For many years he had used the open method, and
during the war in 1866 all amputation wounds were treated in
this way. He also employed immersion in water containing
carbolic acid : recent wounds of the hands and feet were placed
in vessels containing this solution. In his earlier cases the
wounds were stitched, drainage being provided for, but for the
four years preceding the adoption of the aseptic method — i.e.
up till 1872 — he left the wounds quite open. During the first
years in which these methods of treatment were carried out,
the results were very favourable, and Volkmann was thoroughly
conWnced of theu" superiority over the older modes. As time
went on, however, and as overcrowding of the wards became
necessary, infective diseases also progressively increased, and at
last, in the summer and autumn of 1871, the deaths from
pvfemia and septicaemia were so numerous that he made up
his mind to shut up the hospital altogether for a time. Before
doing so, however, he thought that he would try the Listerian
method for a few weeks, and it is to the result of tliis trial that
I now wish to refer.
c c
386 RESULTS OF ANTISEPTIC SURGERY.
T need not go into the details which he gives as to the
hygienic conditions of the hospitaL They seem to have been
very wretched. There were no proper arrangements for venti-
lation ; waterclosets opened into the wards ; there was no place
for keeping the dead bodies, which were therefore laid in a
cellar situated beneath the surgical wards, and the wards were
full of beds. It was under these conditions and in this infected
atmosphere that the aseptic method was first employed.
Volkmann's first report extends from December 1872 to
February 1874.^ This was the period in which he was learning
the method, and I shall not, therefore, refer at length to his
results during this time. Among the cases in which the aseptic
method was tried there was one death from pyaemia and one
from erysipelas. Erysipelas attacked eight wounds treated on
aseptic principles. There were other cases of infective diseases
in the hospital during this time, but these were either admitted
while suffering from them, or they arose in cases not treated
aseptically.
This remarkable result was obtained in a hospital which,
at the commencement of this period, was going to be closed on
account of the enormous mortality from these diseases. Surely
here there was some benefit derived from the introduction of
the aseptic method ! And it must be noted that these two
deaths from infective disease occurred in the early period of
aseptic practice and, with regard to them and the erysipelas
cases, Volkmann states that he could generally point out an
error in the manipulations, as a rule, in the mode in which the
■dressing was applied. In a note written in 1875 Volkmann
states, that during the last eighteen months,'^ i.e. from the
middle of December 1873, there had been no case of pyaemia,
and erysipelas had almost or altogether disappeared. With
regard to these results Volkmann expressly shows that they were
not due to the mere use of carbolic acid as a disinfectant, for
carbolic acid had been, as I have just stated, extensively em-
' Beitrdgezur Chirurgic, 1875 : ' Ueber den Antiseptischen Occlusiv Verband
und seinen Kinflnss auf den Heilungsprocess der Wiinden ; ' Volkmann's
Sammlimg, No. 96, 1875.
- In the Appendix Volkmann states that this holds true for metastatic
pyiEmia, but that only fifteen months had elapsed since he had a case of
•I'yaimi a simplex.' ^
VOLKMANNS STATISTICS.
387
ployed during the preceding period to irrigate wounds, but
latterly without any ap2:)arent benefit.
In 1877 Volkmann published the continuation of this
report,^ and I will refer to it in some detail. The report extends
from March 1874 to March 1877, a period of three years. He
does not give all the cases treated, but, omitting the septic
cases, there is a record of 465 operations performed with aseptic
precautions. Of these cases 29 died.
Among these 465 operations were 157 amputations, of which 15
died. On analysing these cases of amputation we find that 139 of
them were uncomplicated with other injury or mutilation, and of
these only 4 died. Three of these deaths occurred within the first 24
hours from shock, and 1 from ' habitual erysipelas.' Omitting from
this list 7 partial amputations of the foot, there were 132 major
amputations, with 4 deaths, or, leaving out the cases of shock, which
were of course independent of the method of treatment, there were
129 major amputations, with 1 death.
The following is the list arranged in a tabular form : — -
Amputation at the shoulder-joint
through humerus .
„ forearm .
at wrist -joint .
„ hip-joint
through thigh
leg .
at ankle (Syrae and Pirogoff)
partial of foot
Total .
Cases
Death
4
1*
14
• —
23
—
3
—
2
1*
42
]*
2,5
If
19
—
139
Died from sliock ; f from ' habitual erysipelas/
There were 9 CJises of double amputation.s, with 2 deaths ; 1 died
within a few houi-s, and 1 died on the third day (amputation through
both thighs) with symptoms of collapse.
There were also 6 amputations in cases where other severe
injuries had been received. Of these 4 died within 24 hours. These
were all very severe cases, as for example, amputation at the shoulder-
' Vorldiitiijrr lim-irht iihcr die innerhalh drr Iriztfii drei Jahre in der chi-
rurginrkrii. Klinik zii JIalle utafiondr odcr jjnlikliuiseh mit Hiilfr der AntUrp-
tischen, }[ctlindt' hrhnitdt'Uen xchiccreib Opcratvmen and Kchtvcren Verl.rtzuiigen.
By Volkmann and Kraske, Halle, 1877.
c c 2
388 RESULTS OF ANTISEPTIC SURGERY.
joint with fracture of sternum and ribs ; fracture of the skull, fracture
of ribs, and amputation through both thighs, &c. One case died on
the fourth day, never having recovered from the state of collapse ;
here amputation through the thigh had been performed, and the
patient had also sustained a severe bruise of the abdomen. One case
of amputation of the thigh, along with a severe injury to the hand,
died of tetanus on the 14th day.
Lastly, 3 cases died of intercurrent diseases. These were a case of
amputation thi'ough the leg, which died of delirium tremens ; an
amputation through the femur, from pneumonia, on the 21st day, the
wound being practically healed ; and a case of amputation through
the humerus, in which abortion occurred, followed by the patient's
death from puerperal fever.
Ninety-one excisions. of joints were performed, with 5 deaths :
2 excisions of the hip died from shock ; 1 excision of the hip from
haemorrhage 3 j months after the operation ; 1 excision of the hip from
thrombosis of the iliac vein two months after the operation : 1 exci-
sion of the knee from tubercular meningitis. A-Qiong these cases
were 44 excisions of the hip, which recovered. Two cases died from
intercurrent disease, viz., 1 excision of ankle-joint from delirium
tremens, and 1 excision of the shoiilder-joint from phthisis and
haemoptysis. Thus thex-e were in all 93 cases of excision of joints
with 7 deaths.
There were 10 operations for uniinited or badly united fracture
withotit a death. Also 50 cases of osteotomy, of which 1, a patient
affected with the hoemorrhagic diathesis, died from haemorrhage.
There were 45 cases of hydrocele treated by opening the sac, stitch-
ing it to the skin and introducing a drainage tube. No bad result.
There wore 119 excisions of the mamma in 110 patients. Among
these were 75 cases in which the fat and glands in the axilla were
also i-emoved. Of the 110 cases 6 died; 1 from shock, 1 from
anthrax, which Volkmann thinks must have been introduced with
the cat-gut, 2 from exhaustion in old people, 2 from erysipelas — in 1
case arising from a bed-sore, and in the other commencing after the
antiseptic dressings had been left off.
Up to this time Volkmann had treated seventy-three com-
pound fractures a:nd twenty-four wounds of joints conservatively
without a single death.
Adding together the whole results, we find that 562 serious
operations and injuries were treated, with twenty-nine deaths,
not one of these being due to infective disease arising under an
NUSSBAUM. ' 389
antiseptic dressing, Volkmann further states that not a single
case of pyaemia or septica3mia occurred among patients treated
asepticallj during these three years. Erysipelas attacked
three or four of the cases which were treated on aseptic prin-
ciples.
Here is a piece of evidence which cannot be overlooked.
Into an infected hospital the aseptic method was introduced
without any other change being made in the arrangements of
the hospital. At once the infective diseases, which were attack-
ing almost every patient, disappeared in the cases treated
aseptically, only one case of pyaemia and about twelve of ery-
sipelas occurring dui"ing more than four years, and almost all of
these arising at the very commencement of the trial when as yet
the surgeon had not had sufficient experience of the working
of the method. When this experience was obtained, these
diseases practically entirely disappeared. In estimating these
results at their proper value, we must also remember that
during the aseptic period, operations were performed and limbs
preserved in a way impossible in an infected atmosphere. What
would have been the result of the 1 50 operations on bones, or of
the hydrocele cases, or of the wounds of joints, or of the com-
pound fractures in the former infected atmosphere, if they had
not been treated aseptically ? What would their result have
been in a good atmosphere, such as St. Bartholomew's hospital
is said to possess ? Would there have been no infective diseases
there ?
Similar remarkable facts have been published by Professor
Nussbaum of Munich, who commenced aseptic treatment two
years later than Professor Volkmann. The ' Allgemeines
Krankenhaus ' at INIunich, though by no means very deficient in
sanitary arrangements, became infected with septic diseases, so
that almost every case of open wound treated in the wards was
attacked by them. Pyaemia was rife, affecting nearly all cases
of compound fracture or Wounds of bones, amputation wounds,
&c. ; erysipelas was constantly present. During 1872, hospital
gangrene also appeared, and steadily spread in spite of all the
precautions which were taken. In 1872, twenty-six per cent, of
all the wounds were attacked with hosi)ital gangrene, and during
1873 the proportion increased to fifty and ultimately eighty per
390 RESULTS OF ANTISEPTIC SURGERY.
cent. Erysipelas, too, which in 1872 was comparatively mild,
became much more virulent and frequent. All this occurred
in spite of the use of antiseptics, of the open method, &c.
In an address delivered in 1875, at the end of the academi-
cal year,' Professor Nussbaum mentions these facts and describes
also the results which followed the introduction of strict a^ptic
treatment. With regard to his former results, to which I have
just alluded, he says that he had employed in the treatment of
wounds the open method, various forms of occlusion, continuous
water-baths, chlorine water, carbolic acid, salicylic acid in pow-
der and solution, Mr. Lister's carbolic paste, and even the car-
bolised gauze dressings. ' Alles, alles,' says he, ' war nicht im
Stande, den Hospitalbrand, die Pysemie zu bekampfen.' With-
out any other change, strict aseptic treatment was used in all
possible cases, and then, he says, at once they experienced one
surprise after another : everything went well ; there was no
more hospital gangrene, though a week or two previously eighty
per cent, of the wounds were suffering from it ; pyaemia and
erysipelas were only observed in one or two cases, and these
disappeared as skill in the use of the method was acquired.
Nussbaum adds : ' One might reply ' (to these facts), ' pyaemia
and hospital gangrene are diseases which often suddenly attack
a hospital without any apparent cause and often also suddenly
disappear. But think, my friends, that during the sixteen
years in which I have had charge of this hospital pyaemia has
not been absent a single month, and yet it suddenly disappeared
on the introduction of the Listerian method.'
A year later. Dr. Lindpaintner, Professor Nussbaum's assis-
tant, published a detailed account of Nussbaum's practice from
April 1st, 1875, to the end of March 1876.2 j ^^^^\l ^ot enter
at length into these results, but there are some points to which
I must call attention.
During this period there were 459 operation or accidental
wounds under treatment, and of these twenty-six died. The
cases were not all treated aseptically as will be evident when I
consider the causes of death, to which I must now allude.
' Die Chirimiiitclie Kliriih en Mwichcn im Jahre 1875; Stuttgart: Fred.
Enkc, 1875.
^ Dcutuclir Zcifschrift far CMritrgie.
XUSSBA UM. 891
Three cases in which primary amputation was performed died
in a few houi's. Other extensive injuries were present in all these
instances.
One patient, ast. 79, died suddenly of cerebral hsemorrhage 31 days
after resection of the elbow joint.
In one case a malignant tumour of the scalp was removed, and
the disease was found to have perforated the skull. Recurrence
rapidly took place, and the patient died with symptoms of com-
pression.
One case of gunshot wound of the skull and brain went on well
for 11 days, and then died suddenly. Cause unknown.
A large abscess of the mamma connected with caries of the ribs
was opened aseptically, and was progi-essing typically, when death
occurred suddenly on the 3rd day. Cause unknown.
One case of large ulcer of the leg, which had healed, died of phthisis
nearly 4 months after admission.
One case of extensive abscess of the knee-joint, which was incised
aseptically, died of phthisis 5 months after the operation, the knee-
disease having recovered, and the wound having completely healed.
One case of extensive suppuration in the parotid region died.
There was constant vomiting, and on post-mortem examination
catarrhal pneumonia was found,
A very weak, unhealthy subject, suffering from, compound fracture,
for which secondary amputation was performed, died 5 days after the
operation from thrombosis of the pulmonary arteiy.
One case of excision of the mamma (set. 72) died, and on post-
mortem examinatioti there was found cancer of the lungs, capillary
hfemorrhages in the stomach, and extensive aphthous patches in the
oesophagus. Death was sudden after the existence of difficulty of
breathing for a few hours.
In one case of excision of the mamma peritonitis set in on the 4th
day, though up to that time the patient had been doing well. The
peritonitis was found to proceed from a cancerous tumour in the liver,
which was breaking down.
One case of excision of the mamma died on the 1.5th day from
unilateral pleuro-pneumonia on the same side.
One case of large abscess in the neck, died of ' fibrinous i^eri-
carditis ' 38 days after the abscess was opened, and after it had
healed.
One case of ovariotomy, in which there had formeily been peri-
tonitis, and where extensive adhesions wore present at the time of the
operation, died of peritonitis.
392 RESULTS OF ANTISEPTIC SURGERY.
One case of compound fracture of the leg, which was doing well,
died of myocarditis on the 25 th day.
One case of resection of the elbow-joint died of cedema of the
lungs and fatty embolism on the 11th day.
One case of compound fracture of the femur in which the bone
was very extensively comminuted and the knee-joint opened, died of
septicaemia.
The remainder of the fatal cases occiuTed in patients not treated
aseptically, and were due to septicajmia, erysipelas, pneumonia,
pysemia, phthisis, peritonitis, and shock.
I have thought it well to mention all the causes of death,
and now I shall summarise what Dr. Lindpaintner says as to
septic diseases.
Erysipelas occurred six times during that year, but not in
any case which was being treated aseptically. It occurred in
four cases of septic wounds, in one case after the Listerian
dressings had been left off, and in one case of excision of the
mamma treated aseptically but spreading from an inflammation
in the neck and never extending under the dressing.
There was no case of hospital gangrene.
There were three cases of septicaemia — one after a septic
operation (excision of the hip), one case admitted with septic-
remia, and one case of compound fracture in which an unsuc-
cessful attempt was made to eradicate the causes of putrefaction
(alluded to above).
There were three cases of pyasmia — one occurring after a
putrid wound in the thigh, one in a case with putrid sinuses
near the elbow-joint, in which no operation was performed, and
one after dilatation of a stricture of the urethra which had
followed a previous amputation of the penis.
There was thus only one case of infective disease among
the cases treated aseptically — the case of bad compound frac-
ture of the femur. Here, of course, the surgeon had not to deal
with a wound made by himself, but with one made without
aseptic precautions, and it is of course always a matter of un-
certainty in such instances whether the wound can be after-
wards rendered aseptic or not. The case of peritonitis after
ovariotomy and the cases of pericarditis and myocarditis might
NUSSBAUM'S RESVLTS. 393
no doubt be attributed to failure in the method. Whether or
not they were due to such a cause, I do not know.
This success in the exclusion of traumatic infective disease
has continued up to the present time in the cases treated asep-
tically, and in a publication of Professor Nussbaum's in 1878,
entitled ' Sonst und Jetzt,' he states that there had been no
further instance of these diseases. It may be interesting to
see what he says : —
Formerly. Now.
* Injuries of the head, compound fractures, am-
putations and excisions, in fact, almost all patients
in whom bones were injured were attacked by
pyaemia. For example, of 17 cases of amputation
11 died from this cause. Even patients with
severe whitlow died of it. .... No pyaemia.
'Hospital gangrene had got the upper hand to
such an extent, that in spite of the open method,
in spite of continuous water-baths, in spite of the
use of chlorine water or the actual cautery, finally
80 per cent, of all wounds and ulcers were attacked,
large arteries being opened into. . . . No hospital
gangrene.
' Almost every wound was attacked with erysi-
pelas No erysi-
pelas.'
Still later, in the last edition of his work on antiseptic
surgery, published in 1880, the same statement is reiterated
and Nussbaum now says, that since the introduction of the
aseptic method there has been no instance of pya-miu, hospital
gangrene or erysipelas among the patients treated in that way.
And yet, he adds, no other change has been made ; ' the wards,
the furniture, the nursing of the patients and their number
remain the same.'
Indeed, in summing up his five years' experience he goes so
far as to say that ' any recent wound, treated by this method, is
guaranteed against pyaemia, hospital gangrene, erysipelas, pro-
gressive suppuration, and in general against all accidental com-
304 liESUlTS OF ANTISEPTIC SURGERY.
plications.' And further : ' The fate of a })atient seriously
wounded is almost entirely in the hands of the surgeon who
applies the first dressing.' Such is Nussbaum's experience after
using this method for five years in a hospital in which infective
diseases were very prevalent.
These facts cannot be overlooked, and are of the very greatest
value — of much more value than any number of results in
healthy hospitals. For here we have an immediate abolition of
traumatic infective diseases, only one case occurring in five
years, and that after a wound not made by the surgeon ; there
was thus not merely a great diminution in the frequency of
these diseases but absolute cessation. These facts, when
surgeons in this country have deigned to notice them, have
been attributed to increased cleanliness alone, the result of the
introduction of strict aseptic precautions. It is asserted, and
the assertion no doubt holds good in many places, that dirty
sponges, dirty instruments, &c., were used in dressing the
various cases, and that no care was taken to cleanse the instru-
ments after their use, nor to keep apart those employed in bad
cases. I venture, however, to affirm that these objections do
not apply to the practice of such men as Bardeleben, Esmarch,
Hueter, Nussbaum, Volkmann, and many others whom I might
mention — men who are at the head of the surgical profession,
and who owe their high reputation to their thorough knowledge
of physiology and pathology. In Professor Nussbaum's case this
objection cannot be upheld for one moment, for he had charge
of two hospitals, one in the country placed under good hy-
gienic conditions, and the other in town not so well situated in
these respects. The same surgeons and the same methods of
dressing and nursing were employed in the one institution as
in the other, and yet the country hospital remained healthy,
while the one in town became infected. Surely the same un-
cleanliness would have told, at least to some extent, in the
country as in the town. But further it must be remembered
that the result of the use of the aseptic system was not "merely
the diminution, but the abolition, of these infective. diseases.
Now cleanliness, as advocated b}^ Mr. Savory— and I shall refer
to this matter again — does not result in the abolition, but merely
in the diminution of these affections, and I do not allow that
NTJSSBAUM: SOCIN : SAXTORPH. 395
the results which Mr. Savory gives were solely clue to clean-
liness as distinguished from asepticism.
Then, again, these diseases disappeared at once, for Nuss-
baum tells us that from the day when he began this treatment
thoroughly, these diseases never attacked any of the cases so
treated. What an extraordinary amount of cleanliness would
be required to effect this ! But indeed we are told that clean-
liness alone had not been able to abolish these diseases, even
after several yeai's'^ practice of it, for Nussbamn says in 1878,*
that even then a tracheotomy or other wound which could not
be treated aseptically was liable to be attacked by erysipelas of
as severe a type as formerly. And, further, Nussbaum had been
practising cleanliness before the introduction of the aseptic
method; for many of the wounds were irrigated with anti-
septics, such as carbolic acid, &c., without any apparent benefit.
Cleanliness is, no doubt, a most excellent thing in its own
place, but its power as a preventive of infective disease in an
infected atmosphere is very limited indeed.
And lastly, it cannot be said that Nussbaum does not now
diagnose as infective disease cases which he would formerly
have classified under that heading, for post-mortem examina-
tions are made on all the fatal cases by Professor von Buhl,
quite independently of Professor Nussbaum, and thus any such
error would be corrected. Nussbaum remarks in a note to
Mr. MacCormac (' Antiseptic Surgery *), ' the mortality is
reduced to one half, and the only cases brought to the
postmortem room are those of death by suicide, from severe
mechanical injury, in old people, or from cancer and tubercle.'
Socin of Basle uses language very similar to that of Nuss-
baum with regard to the occurrence of infective diseases. He
has also observed their complete disappearance under aseptic
treatment, and as the result of his experience, he says that,
' Every case of amputation which dies of pyaemia or of erysipelas
is a victim of ignorance, of want of skill or of negligence on
the part of the surgeon.'
Saxtorph of Copenhagen has had an experience similar to
that of Volkmann and Nussbaum. His results are quoted at
considerable length in Lucas Championniere's ' Chirurgie Anti-
' Songt vnd Jctzt.
396 RESULTS OF ANTISEPTIC SURGERY.
septique,' to which I must refer the reader. I may, however,
just mention the following facts.
Before 1873 Saxtorph had performed 15 excisions of joints,
of which 9, or 60 per cent., died. These wounds were treated
in the ordinary manner. He then introduced aseptic pre-
cautions, but they were very imperfectly carried out. During
this period (between 1873 and 1877), he performed 76 ex-
cisions of joints with 32 deaths, or a mortality of 42 per cent.
The method was then carried out more efficiently, and since
1877, 34 excisions of joints (including 15 of the hip and 12 of
the knee), have been performed with 5 deaths, or a mortality of
17 per cent. Indeed, Professor Saxtorph says that since he has
carried out the method with absolute strictness, according to
Mr. Lister's directions, he has performed 24 major excisions
with 1 death (from tetanus), or a mortality of 4*3 per cent.
This result has also been obtained in a bad hospital where
infective diseases were common. The increased success, ac-
cording as more efficient precautions were taken to exclude
the causes of putrefaction, is very interesting and important.
Another strong advocate of the aseptic method is Professor
Esmarch of Kiel. In 1875, he introduced the method into his
wards, which had previously been especially liable to attacks of
erysipelas. The report of the first year in which Esmarch em-
ployed this method is published by Waitz in ' Langeubeck's
Archiv ' for 1877, and he states that 536 operation cases were
under treatment during that year, and of those treated aseptic-
ally only four were attacked by erysipelas (one of these cases
died). Two patients who were treated aseptically died with-
out any definite symptom except the presence of a continuous
high temperature — septicaemia (?). Two cases died of pyaemia,
but neither of these tell against the method ; one was a case of
acute necrosis where an abscess was opened, but where, never-
theless, pyaemia carried off the patient ; the other was a case
of herniotomy, in which the gut was found to be gangrenous.
These results were very good for the first year of aseptic
work, but as Esmarch and his assistants gained experience, the
cases of infective disease became fewer and fewer. His report
for 1878 is alluded to by Mr. MacCormac,' who states that
' Antiseptic Surgery.
ESMARCH. 397
Esmarch had during that year treated 524 cases with 25 deaths.
These cases include forty amputations, 27 major resections, 80
cases of removal of tumours, &c. Mr. MacCormac gives a list
of the causes of death, and among them were two from septic-
aemia after excision of the mamma, presumably performed
aseptically, though that is not expressly stated ; no facts are
given with regard to them. One case of ovariotomy died from
peritonitis. In this, as in many other reports, no separation
is made between cases dressed aseptically and those treated by
other methods.
Mr. MacCormac states that Professor Esmarch informs him
that- his next triennial report will show better results. A part
of this report is already furnished by Dr. Neuber, in his last
communication on absorbable drainage tubes and permanent
dressings.*
Between the end of April and the beginning of October, 1879, all
the cases treated aseptically wei'e di'essed in this way. These were
131 in number, comprising 5 amputations of the thigh, 7 amputations
of the leg, 1 at the knee-joint, 1 through the humerus, and 1 through
the fore-arm ; 2 excisions of the knee-joint ; 4 excisions of the
mamma and axillary glands ; 5 excisions of the mamma alone; 16
excisions of large lymphatic glandular tumours from the neck varying
from 1 to 2 fists in size; 16 excisions of other tumoiu-s, &c. During
this period 3 patients treated aseptically died, viz., one case of ex-
cision of the hip fi-om shock ; one case of removal of carcinoma from
the ear of a patient (jet. 70), in wliich there Avere secondaiy aftections
of the glands in the neck, &c., from hypostatic pneumonia; and one
patient, who was suifering from septicaemia before his thigh was
amputated, and who afterwards died of that disease (not a case in
point).
During the next 2 months 60 additional cases were treated in this
way without a death. These comprised am])utations, resections,
compound fractures, removal of tumours, &c. Thus during these 8
months 191 cases were treated aseptically with 3 deaths, but in no
instance did infective disease arise aftei- the operation.^
' Uebir die VerandvnnKjvii dccalcinirter Knochenrohrcn in, Weichtheils-
jvuiiden, 4'e. ; Lanyenbeck's Archiv, Bd. xxv.
2 At the Jnternatioual Medical Congress of this year, Prof. Esniarcli
brought forward still more recent statistics. Tlie cases were treated bv
>\euber'b method of permanent dressings, the antiseptic chielly employed in
398 RESULTS OF ANTISEPTIC SURGERY.
Perhaps the earliest in Germany to take up asepticism was
Professor Hueter of Grreifswald, and he still looks on it as the
best method and the ' greatest advance of modern surgery.' He
uses salicylic jute instead of carbolised gauze, not because he
believes it to be better, but because it is cheaper.
Professor Czerny of Freiburg also added his evidence in
1876.' The number of cases to which he alluded was not
great, but in his address at the end of the summer session,
1876, he stated that he had been unable to show his class a
single case of pyaemia, hospital gangrene, or septicaemia during
the whole year. He had two cases of erysipelas, one of these
occurring after sequestrotomy and attempted purification of the
sinuses with chloride of zinc. (This was not a case operated
on from the first aseptically.)
Czerny says that in former years, with the exception of
1875, during which aseptic treatment had also been employed,
he had always had a considerable number of cases of infective
disease in the wards. The abolition of these diseases could
not, he says, be due to anything in the arrangement or service
of the wards, for these remained unaltered. They were as
full as formerly, as imperfectly ventilated, and the watercloset
arrangements were unaltered. A greater number of patients
were treated. The results had steadily improved with in-
creased care in carrying out all the details ; and his belief is
that 'the favourable results which have followed the intro-
duction of this method are to be ascribed to the accuracy
with which Mr. Lister's directions have been followed.'
In France this method was first taken up by Dr. Lucas
Championniere, whose text-book and other w^ritings - on the
the dressings having been Io(loft)rm. They had recently treated 3*J8 cases of
major operations and injury with 6 deaths. There was no instance of in-
fective diseases. The cases were 146 excisions of large tumours, including 40
excisions of the mamma and axillary glands and 14 castrations with three
deaths — 1 from pericarditis and old syphilis, 1 from apoplexj', and 1 from
fatty heart ; 61 resections ; 51 major amputations (18 of thigh, 27 of leg, 5 of
arm, 1 of forearm), with 2 deaths — 1 from shock and haemorrhage, and 1 from
delirium tremens; 11 exarticulations 26 necrotomies ; 13 nerve stretchings,
including one for tetanus, which was fatal; 8 herniotomies; 21 chronic
abscesses ; 12 large wounds ; 4i) compound fractures.
' Berlin. Klin. Wockcnschriff, 1876, No. 4:?.
* ChiTurf/lc Aidiscjjtiqiw.
SCHEDE'S STATISTICS. 39&
subject, are now so well known. He also finds that pytemia,
septicsemia, and hospital gangrene disappear when aseptic
treatment is employed. He has at times observed erysipelas
under this dressing, but the disease was very rarely present and
of a very mild ty|)e.
As the result of the writings of Lucas ChamjDionniere,
several French surgeons have introduced this method, but it
has not as yet taken the same hold in France that it has in
Germany. Those, however, who have used it properly make
the same statements as to complete disappearance of infective
disease. Among those who have employed this treatment and
who have got these results may be mentioned M. Gross of
Nancy, who has written a text-book on the subject.
M. Letievant, of Lyons, is also an enthusiastic supporter of
this system.' He introduced it into his wards during the
summer of 1875, and from that time pygemia disappeared and
the mortality after operations and wounds greatly diminished.
His statements with regard to infective disease are : ' Purulent
infection has disappeared. Hospital gangrene has disappeared.
Erysipelas is much rarer and less severe.'
Professor Panas ^ also found that dming a virulent epidemic,
those of his patients at the Lariboisiere who were treated
aseptically escaped erysipelas and other septic diseases.
Keturning to Germany, there still remain two pieces of
statistics to which I must refer.
The first is Schede's comparative statement of the results
of amputations treated aseptically and of those treated in other
ways.'^ The aseptic cases were under the care of Busch, Schede,
Socin and Volkmann. The cases not treated aseptically were
furnished by Bruns, Bardeleben and Billroth.
The most important tables give the result of uncomplicated
amputations performed aseptically, contrasted with those
treated by other methods.
Uncomplicated amputations treated aseptically : —
Note sur le paitnemeiit anti»vptique listerien a VHotel-Dieu de Lyon,
1880.
^ Gazette hsbdomadaire, 1878.
" Amj)utatiaiirn und Il/'xcctioiwn. Handbiioli dor albjiiiwliu- und sprciclh-
Chiruvfju; Tilha und Billroth.
400
RESULTS OF ANTISEPTIC SURGERY.
At shoulder- joint
Through humerus
„ fore-arm
At wrist-joint .
„ hip-joint
Through thigh .
At knee-joint .
Through leg
Partial amputations of foot (including 9 Sj'me's"1
amputations, 36 Pirogoff's, 15 Cliopart's, 1 ^
Lisfranc, 4 of metatarsal bones)" J
Cases
Deaths
9
1
32
—
47
—
4
—
6
4
86
6*
3
—
69
It
65
Total ... 321 ]4
A mortality of 4-4 p. c.
* One of these deaths was due to septicemia ; f from 'habitual erysipelas;
§ one from ' pytemia simplex.'
Uncomplicated amputations treated by the older methods:—
Deatlis
At shoulder- joint
Through humerus
„ fore-arm
At wrist- joint .
,, hip-joint
Through thigh .
„ knee-joint
leer
Partial of foot (8 Lyme's amputations, 13"|
Pirogoff's, 5 Malgaigne's, 9 Chopart's, ^ 39
1 Lisfranc, 3 of metatarsal bones J
15
8*
41
6t
42
2
10
—
3
n
105
43§
7
111
115
381
10*
Total ... 377 110
A mortality of 29-18 p. c.
*f All from infective disease; J one from pyEemia; § thirty-eight from
infective disease ; || from pyjemia ; 1 thirty-seven from infective disease ;
** nine from infective disease.
Other tables are given stating the results of double ampu-
tations, of amputations with other severe injviries, of amputa-
tions in existing septicaemia, pyaemia or tetanus, and of deaths
from intercurrent diseases quite unconnected with the operation.
I need not, however, go into these, as they would only obscure
the point at issue.
Schede tabulates the causes of death in the two preceding
tables as follows : —
REYHERS STATISTICS. 401
In the septic In the aseptic
• cases cases
Pj'Eemia 72 0
Septicsemia ....... 19 1
Erysipelas ....... 2 1
Trismus ........ 0 1
Pyaemia simplex ...... 6 1
Hasmorrhage ....... 'S 1
Pjxhaustion ....... 2 1
yhock 6 8
Total .... 110 14
Thus, as Schede truly remarks, if the deaths from infective
diseases were removed from the list of septic cases, the death-
rate in each would be almost the same — about 5 per cent, for
the septic cases, as against 4*4 per cent, for the aseptic. In
other words, the aseptic method saved this enormous propor-
tion of lives in the main by preventing infective disease.
The last paper to which I shall refer is Reyher's account of
his results during the Russo-Turkish war.' As I intend to
discuss these results later I shall just mention the numbers
here.
Eighty-one cases were treated aseptically as soon as pos-
sible after the injury, and of these 15 or 18*6 per cent. died.
Among these cases were 27 gunshot wounds of joints treated
conservatively throughout with 4 deaths ; 1 9 primary resec-
tions in cases of gunshot wounds of joints with 2 deaths ; 13
primary amputations with 5 deaths ; and 22 compound frac-
tui'es with 4 deaths. Of the 1 5 deaths, 5 were due to septic
diseases (2 to pygemia, and 3 to septic inflammation and sup-
puration). With regard to the deaths from septic diseases in
these cases, we must remember that here the surgeon had not
to deal with an operation performed by himself, in which the
problem is to keep out the causes of putrefaction, for here the
causes were in many instances already present. The deaths
occurred in cases where these causes were present and were
not destroyed because portions of clothing, &c., were present in
recesses of the wounds-
Contrasted with this were 65 compound fractures and 78
' Volkmann's Sainmlitiif/, Nos. 112 and 113: Iflc a/itlnrjHiscfie WuiidbcJiand-
litiigindcr Ki-icysckirurgic, 1878.
n D
402 BESULTS OF ANTISEPTIC SURGERY.
wounds of joints, in all 143 cases, which did not come under
treatment for some time, and in which the generally unsuc-
cessful attempt at purification was made. Where these at-
tempts are unsuccessful the treatment resolves itself into
treatment with antiseptics. Of these 143 cases treated with
antiseptics, 71 or 49*6 per cent, had already died when the
first part of the report was issued, and 2 more died subsequently.
Of these at least 46 cases died of septic diseases.
Then contrasted with both these sets of cases there were-
treated alongside of them 62 wounds of joints, in which no
attempt was made to render the wounds aseptic, or even to
treat them with antiseptics. Of these, 48 or 77*4 per cent,
had died when Eeyher wrote, and amputation or resection had
been found necessary in most instances.
Lastly, I would allude to the results obtained in ovariotomy
by the leading ovariotomists of this country. Mr. Spencer
Wells and Dr. Keith had for years striven to carry out perfect
cleanliness and other antiseptic precautions short of complete
exclusion of organisms from wounds, and the results of both
were very remarkable indeed. And yet, since they have ex-
tended their precautions so as to exclude the causes of fermen-
tation, their results have still further improved, and they
themselves — and they are the best judges — attribute this last
improvement solely to the additional antiseptic precautions
employed.
Mi\ Knowsley Thornton, in his speech at the debate on
antiseptic surgery in December, 1879,' gave an analysis of
more than 300 cases of fatal ovariotomy, and stated that in
more than one-third of the cases septicaemia, pys'mia or septic
peritonitis were given as the cause of death, and in nearly
another one-third the fatal result was attributed to peritonitis.
]Mr. Thornton pointed out further that the cases of peritonitis
were almost entirely due to septic causes, and thus, as he
states, two-thirds of the deaths after ovariotomy were due
to septic influences, and therefore, if these influences can be
eliminated by aseptic surgery, the results ought to improve
to a corresponding extent. And he states that this has been his
experience, and that the introduction of strict aseptic precau-
' MacCormac's Aiitixcjiflc Surgery.
RESULTS IN OVARIOTOMY. 403
tions has reduced his mortality by half, and it would have been
still less had not putrefaction been present in some of the
cases before he operated, owing to previous tapping of cysts
by other surgeons without aseptic precautions.
]\lr. Spencer Wells, at the same meeting, spoke very
strongly in favour of aseptic treatment, and gave the result of
the last 168 cases which he had treated in private practice.
The first 84 had been treated by his former methods, but yet,
he says, ' with all the care I could give to them there were 21
deaths.' On the other hand, the last 84 were treated asep-
tically, and of these only 6 died, and these deaths occurred
among the earlier cases while he was only as yet making
acquaintance with the details of the method ; and so ' as I
went on and became still more accustomed to the method and
details of antiseptic treatment, and avoided mistakes, then I
obtained the long run of 38 cases without a single death ; and,
adding to that the 5 more of other important abdominal opera-
tions, I can record the gratifying and almost incredible result
of 43 cases of these great operations without a death.' In a
foot-note he adds : ' The run of 38 cases of successfid ovari-
otomy was afterwards increased to 41, and then a death
occurred where septic symptoms had set in before operation.'
Dr. Thomas Keith, who had adopted the aseptic method
somewhat earlier, and who had previously been getting the
best results of the day, states^ that his last 76 cases were per-
formed aseptically with only 2 deaths, and these occurred at
the couunencement, so that the last 68 cases in succession
all recovered. Dr. Keith is equally positive in ascribing
these good results to the additional precautions whicli he had
taken.^
' See MacCormac"s A/Uin/'ptic Surr/c?'!/.
^ At tlie recent International Congress held in London, Dr. Keith is said to
have stated that he had discontinued the use of the spray. I have not been
able to find a report of his statement, but I can quite imagine that the
amount of car})olic acid poured into the peritoneum by the spray in a prolonged
operation would l;e injurious both from rendering the patient liable to carbolic
acid poisoning, and also from causing an increased amount of fluid in the
peritoneal cavity, wliicli, where the details of the aseptic method were not
thoroughly carried out, would be liable to undergo putrefaction. Though
Dr. Keith lias given up the spray, I have not heard that he has given up the
practice of aseptic surgery. (See Chapter XVTII. for remarks on ovariotomy.)
i» I) 2
404 RESULTS OF ANTISEPTIC SURGERY.
Salicylic acid, which was introduced b3^ Professor Thiersch '
as a substitute for carbolic acid, has been employed in various
hospitals, but the results do not seem to be so good as those
with carbolic acid. The following is a specimen of Thiersch's
earlier results : —
From April 1st, 1874, to May 31st, 1875, 109 cases were treated
with salicylic acid di^essings, and 51 with carbolic acid. Of the former
7 died, of the latter 2. Among the 109 salicylic acid cases were
21 major amputations, with 5 deaths ; also a number of resections,
compound fractures, abscesses, excisions of tumours, &c. The deaths
among the cases treated with salicylic acid were due to the following
causes : In one case from haemorrhage from the intestine 100 days
after primary amputation of one leg and secondary amputation
through the other femur; in one case from hydro thorax 123 days
after primary amputation of the leg ; one patient died on the twenty-
third day after amputation of the thigh, pus being found in the
shoulder-joint ; a case of amputation of the thigh died from ex-
haustion twenty-eight days later ; one case of excision of the head of
the femur died from uraemia twenty-five days after the operation ; one
resection of the wrists-joint, followed by amputation of the fore-arm,
died 201 days after the first operation fiom exhaustion. One of the
deaths in the cases treated by carbolic acid was from pyaemia.
Erysipelas attacked the salicylic acid cases seven times, and
in one instance proved fatal.
The general description of the course of these cases is not
so good as that of cases treated with carbolic acid, and Volk-'
mann and others have tried salicylic acid, but have not found
it so trustworthy as carbolic acid.
Thymol, though at first much praised,^ also soon failed to
give satisfaction. The explanation of this probably was that
in the first instance the thymol was used in wards free from
infective diseases, and therefore good results were at first ob-
tained. But these wards had a great tendency to become
unhealthy on account of the bad hygienic conditions, and the
' ' Klinisc'ie Ergebnisse der Lister'schen Wundbehandlung und iiber den
Ersatz der Carbolsiinre durch Salicylsiiure ' — VnlhnarDi's Sammlnng, Nos. 84
and 85, 1875.
^ Jlcher das Thymol und seine Bcuntzuufi hei der antiscptischen Bchand-
liinf/ der Wundeii, von Hans Kanke, Volkmatni ■^ Santndunfi, No. 128.
TREATMENT WITH ANTISEPTICS. 405
thymol was unable to prevent this in the same way as carbolic
acid had done. Thus bad results were very soon obtained, and
carbolic acid had to be reinstated.
Here is another strong argument against the idea that
cleanliness alone is a sufficient safeguard. In this instance
there was of course the same amount of cleanliness when
thymol was used as when carbolic acid was employed, but a
powerful antiseptic was required in addition to the cleanliness,
and, as the experience before the introduction of Listerism
into these wards had shown, it was necessary to use this anti-
septic on aseptic principles in order to attain the desired object.
The Eelation of other Forms of Antiseptic Surgery
TO Infective Diseases.
I have found the greatest difficulty in getting records of
any value as to the results of treatment with antiseptics not
employed aseptically. I have described Bilguer's method and
results (see p. 302), and these may be taken as a very fair speci-
men of the results obtainable by treatment with antiseptics
alone, though it must be observed that in many instances his
cases were no doubt treated aseptically. I have also, at p. 401,
referred to Keyher's paper giving details of the different results
obtained by aseptic treatment and treatment with antiseptics,
and this is perhaps one of the best contrasts which could be
given. Several of the results which have been published as
having been obtained by strict aseptic treatment are in reality
nothing of the kind, but are merely the results of treatment by
antiseptics and they might very fairly be used as such. And
it woidd be seen from these that though infective diseases are
often much diminished in frequency, yet they are by no means
entirely abolished. Indeed, the rapid manner in which carbolic
acid began to fall out of use before Mr. Lister published, shows
tliat it was found to be inefficient when used as an antiseptic
only and not aseptically. I believe that, employed as an anti-
septic only, carbolic acid is inferior to various other substances,
for it combines with albumen, and in doing so apparently loses
in part its antiseptic virtues (see p. 2(iO) ; and therefore, in order
to be efficient, it would require to lie added to tlie discharges of
the wound in large quantities. At the same time its in-
lOG liESULTS OF ANTISEPTIC SURGERY.
efficiency is increased, becanse carbolic acid is very irritating,
and causes an increased amount of discharge liable to undergo
fermentation. And also, as Hack ' has shown, wounds treated
with carbolic acid have greater absorbing power than those
treated with other substances.
The best comparison between aseptic treatment and treat-
ment with antiseptics is that furnished by Mr. Lister's own
results (see p. 376). The cases which were not treated asepti-
cally were, as far as possible, treated with antiseptics. They
were frequently syringed with antiseptic lotions and dressed
with antiseptic ointments and dressings, and yet it will be seen,
that the proportion of deaths avoidable by methods of wound
treatment, and especially of deaths from blood-poisoning, was
much greater than in the aseptic cases, although the nature
of the injuries was much less severe.
At p. 348 I have referred to the results obtained by the use
of alcohol in Nelaton's practice, and I stated that in Chede-
vergne's paper ^ mention is made of 48 cases treated in this
way, of which only 1 died of pysemia.
The cases were, however, not very severe. Thus, there was 1
case of tumour of the lower jaw ; 3 cases of epithehoma of the lip ;
10 partial excisions of the mamma; 2 amputations of the leg; 5
cases of removal of fatty tumours, and a number of isolated minor
operations. There were also 2 cases of wound of the knee-joint and
1 of the elbow-joint, all of which recovered. No details of these cases
ai-e given,
Rochard ^ extends these statistics, and states that 97 patients had
been treated in this way, and that among these there had only been
2 cases of pysemia and 5 of erysipelas,
Chedevergne states with reference to the first part of these
statistics that the results obtained were not merely accidental,
for two cases which had not been treated with alcohol died of
py{x;mia. He attributes the fatal case from pyaemia, mentioned
in his paper, to imperfect application of the dressing, pus
having been allowed to accumulate in the wound.
' Ueher das ResorjJtionsverm'ogen granvlircnder Fliichen, Leipzig, 1879.
^ ' Du traitement des jjlaics cliirurgicales ct traumatiques par les pansements
}\ ralcohol,' BulleUn (/eneral de thi'raiu'vtiqve, vol. G7, 1864.
* Ilistoire de la Chirurgie Fra»qaise au XIX^ Siecle, Paris, 1875.
RESULTS FROM THE USE OF ALCOHOL. 407
In London most excellent results have been obtained by Mr.
Hutchinson by the use of a spirit and lead lotion (see p. 269) ;
and in his speech at St. Thomas's Hospital, at the debate on
antiseptic surgery,' he referred to his results, and stated that
they were as good as those obtained by a colleague who
practised aseptic surgery, but he added that he himself had
abstained from operations which involved peculiar risk.
There can be no doubt of the excellence of alcohol as a
dressing, and the good results are to some extent explained by
Hack's ^ experiments, which show that absorption takes place
with the greatest difficulty from wounds treated with alcohol.
No doubt, also, as Mr. Hutchinson uses it, many of the cases
are treated aseptically.
With regard to these and other results from the use of
antiseptics, I cannot give any tables ; for few surgeons have
employed one antiseptic or one particular method of applying
them, and in London more especially, where almost every sur-
geon uses one or other form of antiseptic treatment, the
results from the various methods of treatment are grouped
together, and are thus almost absolutely useless for the point at
issue.
Among the best of these mixed results— results obtained no
doubt in the main by the use of antiseptics — are the cases of
major amputations performed at St. Bartholomew's Hospital
for the last ten years (1870-79).^ There were 467 major
amputations, of which 7l, or 15'2 per cent., died. These results
include, however, the practice of two surgeons who treated their
cases in the main aseptically.
We have already seen in the historical part that the various
methods of occlusion, acting on the principle of excluding the
gases of the air, have failed to exclude infective diseases. I
need only refer to Jules Guerin's experience during the siege
of Paris, p. 325, and to his refusal to apply his method in a
particular hospital because the atmosphere was ' aussi profonde-
7)ient infects.'
The only method of occlusion which has been of permanent
' See MacCormac's Antiseptic Surtjcry. ^ Lq^ ^jj
* St. Bartholomew^ Hospital licports, 1880.
408 RESULTS OF ANTISEPTIC SURGERY.
service is Alphonse Guerin's ' Pansement ouate ' (see pp. 280
and 325). As we have seen, marked improvement followed its
introduction dm'ing the siege of Paris, and good results are
still obtained in some of the less healthy Paris hospitals.
This method no doubt acts mainly by keeping the layer of
granulations at perfect rest, and thus avoiding its laceration
and the consequent passage of the putrid material — that ' ter-
rible poison,' as Mr. Savory has called it — into the blood.
However good its results may have been in some cases, I can-
not think that a method of treatment in which fluids, under-
going decomposition to a greater or less extent, are retained
in contact with the surface of the wound, and in which the
patient is only protected from the effects of the absorption of
these fluids by maintaining the parts at perfect rest, is one
which can be recommended when better means are obtainable.
The method which perhaps stands next to the aseptic
method in its power of preventing infective disease is treat-
ment by irrigation or the water-bath. Here also definite
statistics fail, but I may refer to Langenbeck's statement (see
p. 344), made in 1855, to the effect that during the preceding
five or six years no case of pyaemia had occurred among the
cases treated by the continuous water-bath. No results are
given as to the other infective diseases, but from what I know
and have seen of this method, I should think that where the
water is frequently changed, especially if an antiseptic is added
to it, and where the wound is not complicated, and there is no
retention of discharges, these diseases would be more or less
completely absent. Langenbeck mentions that dm-ing the five
years to which I have just referred, in which he had no case of
pyaemia among the cases treated by the water-bath, pyaemia
was, nevertheless, prevalent in other wards, and attacked cases
treated in other ways in the same wards.
I referred, also, on p. 345, to Valette's success. He employed
antiseptics to a much greater extent than Langenbeck.
I now come to the consideration of the results obtained by
the use of the open method.
I have already mentioned (p. 332) Bartscher and Vezin's
results. They had 28 cases of amputation (26 of these being
OFEN METHOD: BUROW'S RESULTS. 409
major amputations), with 3 deaths. The causes of death are
not given.
I have also mentioned (p. 333), Burow's results up till 1866.
He had 94 amputations (87 of these being major operations),
with 5 deaths. The causes of death are not stated. In a
later paper (1877), Burow (junior),' gives the results of all the
amputations performed up to that time by his father and him-
self. Since 1866, 29 major amputations had been performed
with 4 deaths, thus giving a total of 123 amputations with 9
deaths, or more jjroperly 116 major amputations with 9 deaths,
or a mortality of 7'7 per cent. Of the 4 last deaths 2 were
due to gangrene of the stump and 2 to pysemia. How many,
if any, of the other deaths were due to septic causes we do not
know.
The following is the detailed list : —
Amputations through thigh
.. leg
„ „ humerus
„ „ fore-arm
„ of foot
Partial of hand
Cases
Dtatbs
as
6*
25
3
25
0
29
0
9
0
2
0
Total . . . 123 9
* 2 certainly from pytemia.
These results are certainly remarkably good. The cases
extended over a period of something like forty years, and were
treated in a small hospital composed of four rooms containing
altogether sixteen beds. These rooms were small and the quan-
tity of air for each patient was not very great. A number of
operations other than amputations were also performed. Thus,
tluring the last ten years given in the paper to which I refer
(1866-76), there were treated, besides the 26 amputations, 53
excisions of the mamma, 30 cases of fistula in ano, 4 amputa-
tions of the penis, 14 excisions of large tumours, 5 excisions
of the upper jaw, 8 excisions of the lower jaw, 6 herniotomies^
G tracheotomies, 5 lithotomies, &c. Thus the conditions were
not so favourable as might at first sight be supposed. We are
not told what the results were in these latter cases, either as
to the occurrence of infective disease or otherwise. Burow
' Archivfiir klimschc Chiriirijie.
41U liESULTS OF ANTISEPTIC SURGERY.
took the most scrupulous precautions as to cleanliness, more
especially of hands and instruments ; for example, he never
employed sponges which had been used before. Then in many
of his cases, notably in the excisions of the mamma, he used
acetate of alumina — a very powerful antiseptic — and he specially
praises its property of keeping down smell.
Much more important facts are published by Kronlein ' in
his report of the results of the open treatment at Ziirich from
18G7— 71. The method employed was chiefly that of Bartscher
and Vezin, but it was combined with frequent irrigation of the
wound with antiseptic solutions, so that we have here, not the
open method pure and simple, but a combination of it with
irrigation and treatment by antiseptics.
Kronlein gives details of the cases of amputation, excision
of the mamma and compound fracture conservatively treated,
and contrasts the results obtained between 1867 and 1871 with
those of the previous 7 years (1860-67). During these 7 years
all sorts of methods of treatment were employed. In some
cases the edges of the wound were brought together by strips
of plaster or by stitches, and covered with compresses and
bandages ; in others the wound was left open for several
hours, &c.
Kronlein discusses from various points of view the causes
of the difference in the results in the two periods, and at length
comes to the conclusion that it is in the main owing to the
different methods of treatment employed. I need not enter
into all his arguments : I quite agree with his conclusion.
During the first period (1860-67), 260 important cases
were treated, and of these 105 died. These cases included
140 amputations, 34 excisions of the mamma, and 86 compound
fractures treated conservatively. Of the 105 deaths 59 oc-
curred from pyaemia and septicaemia alone.
During the second period (1867-71), 172 similar cases were
treated with 34 deaths. These consisted of 85 amputations,
22 excisions of the mamma, and 65 compound fractures. Of
the 34 deaths 12 were fiom pyaemia and septicaemia alone. I
may just quote his tables : —
' Lie offene Wundhehandlung . Ziirich, 1872.
OPEN METHOD: KRONLEINS STATISTICS.
411
Amptitations.
1860-G7.
Cases
Deaths From pyoemia
and septicEBiuia
Thigh 36
31 16
Leg 36
21 12
Humerus . . . . .18
10 8
Fore-arm . . . . .24
4 2
Hand 9
— —
Foot 17
6 4
Total . 140
72* 42t
* Or a mortality of 51-4 p. c.
f Or 30 p. c.
1867-71.
Cases
Deaths From pyfemia
and septicKmia
Thigh 28
10 2
Leg 11
2 1
Humerus 14
2 2
Fore-arm 10
— —
Hand 7
—
Foot 15
3 1
Total . 85
17* 6t
* Or a mortality of 20 p. o.
t Or 7 p. c.
Excic ions of the Mamma.
1860-67.
Cases Deaths From pyiemia and septiciBinia
34 11* " 4t
* Or a mortality of 32-3 p. c. t 11-7 p. c.
1807-71.
Cases Deatlis
22 3*
* Or a mortality of 13-G p. c
From pyaemia and Beptioa'niia
It
t 4'5 p. c.
Compound Fractures treated conservatively to the end.
1860-07.
Thigh
Leg .
Humerus .
Pore arm.
Cases
7
Deaths
2
From pyjemia
aiid septicaemia
0
. 62
13
7
7
3
3
. 10
4
3
. 86
22*
13t
Total
* Or a mortality of 255 \p. c. t 151 p. c.
412 RESULTS OF ANTISEPTIC SUIiGEIiY.
18G7-71.
Cases Dcatlis From pyaemia
and septicaiuiia
Thigh 11 2 0
liSg 31 9 5
Humerus ..... 18 '2 0
Fure-arm 10 1 0
Total . 65 14* 5t
* Or a mortality of 21-5 p. c. t 7-6 p. c.
Kronlein does not give full details of the causes of death
during either period, so that one cannot judge for one's self
how far they were avoidable or not. He confines his attention
to infective diseases.
If we analyse Kronlein's tables of amputations in the same
way as was done on p. 387, for the septic and aseptic tables,
i.e., if we only consider uncomplicated amputations, leaving out
of consideration double amputations, amputations where other
injuries were present, amputations in patients already suffering
from septic poisoning, &c., we get the following results in cases
treated by the somewhat modified open method described
above : —
Uncomplicated A mputations.
(1867-71.)
Cases Deaths
Humerus 13 3
Fore-arm 8 0
Hand 7 0
Thigh 22 5
Leg 5 0
Partial of foot 12 3
Total . . 67 11
or a mortality of 16-4 p. c. as compared with Schede's result in aseptic cases
of 4-4 p. c. Of these deaths one occurred from shock ; in live no cause of
death is given ; four died from pyaemia ; and one from erysipelas.
Between 1860 and 1867 about 4,000 patients, suffering
from all sorts of affections, were treated in the surgical wards
at Ziirich, and of these 146 died of pyaemia and septicaemia.
Between 1867 and 1871 about 2,300 similar cases were
treated. Of these only 19 died of pyaemia and septicaemia.
Among the 4,000 patients of the first period erysipelas oc-
RESULTS OF THE ORDINARY METHODS. 413
curred 148 times. Among the 2,300 patients of the second
period erysipelas occurred 127 times.
We thus see, that a treatment consisting of a combination
of the open method with intermittent irrigation and treatment
with antiseptics reduced in a very marked degree the mortality
from pyasmia and septicaemia, but did not affect erysipelas at
all. What the open method alone would have done we do
not know, but these results are very good in a hospital where
infective diseases were prevalent. Kronlein himself says
that these cases ' sufficiently show that the open method is
no absolute guarantee against pyaemia and septicgemia.' He
also states that 'the open method does nothing against ery-
sipelas ; indeed, during the time in which the open method
was employed, erysipelas was more frequently observed than
formerly.'
We have also already seen from the experiences of Nuss-
baum and Volkmann, that the open method is not very power-
ful against septic diseases in infected hospitals. Thus, for
example, Volkmann states that at first he was an advocate of
the open method, but that by-and-by, as the hospital became
more and more unhealthy, the treatment became of less and
less value.
I may, in contrast to the results of the foregoing methods,
give a few statistical tables of cases not treated aseptically at
all.
Billroth's results just quoted in Kronlein's book represent
the mortality after operations not treated aseptically.
Malgaigne's statistics ^ are well known. The following
table of amputations represents the results obtained in Paris at
the time when he wrote.
Amputation of thigh
» leg .
Partial of foot .
Cases
. 201
. 192
. 38
Deaths
126 =
106 =
y =
mortality of 62-6 p. c.
„ 55-2 „
» 23-6 „
yhoulflei-joint .
. 13
10 =
» 76-9 „
Humerus .
91
41 =
:, 45 „
Fore -arm .
. 28
8 =
„ 28-5 „
Total . 563 300= „ „ 53-2 „
' ATc/dv(S (jv III rales ilc Mcih-cinc, 1842.
414 RESULTS OF ANTISEPTIC SURGERY.
Paul ' has collected a very extensive series of statistics, of
which the following is a sample.
Amputation
at hip-joint
222
159 = ]
mortal
ityof 71-6
))
through femur .
1721
863 =
„ 50-1
,,
at shoulder-joint
192
84 =
„ 43-7
„
„ knee-joint
49
24 =
„ 40-9
,,
through leg
1242
480-
., 38-7
,,
„ humerus
943
314 =
„ 33-3
'^
„ fore-arm
391
73 =
M 18-7
Total . 5,060 1,997= 39-4
Mr. Holmes in 1866 - gave statistics of the last 300 ampu-
tations performed at St. Greorge's Hospital. Of these, eighty-
three or 27*6 p. c. died. In 1874^ he published statistics of
the last 500 cases of amputation, and, of these, 158 or 31 "6 p. c.
died. It thus appears that of the last 200 amputations per-
formed at St. George's Hospital between 1866 and 1874, 75 or
37*6 p. c, died. This result shows that but little benefit had
been derived from the recent improvements in surgery as
regards cleanliness, &c., apart from the use of strict aseptic
treatment, because the majority of these cases were treated
after attention had been called to the subject by Mr. Lister's
writings.
]M.r. Erichsen^ says that the mortality after great amputa-
tions varies from 35 to 50 p. c.
The results obtained at St. Bartholomew's Hospital were
brought forward by Mr. Savory at the meeting of the British
Medical Association at Cork ''in 1879 to show what could be
done simply by cleanliness and good ;vir independently of
aseptic treatment. The report published in 1880^ shows that
of 619 operation cases of all kinds (excluding eye operations)
45 or 7*2 p.c. died. Many of these operations were of very
minor importance indeed. They included, however, 73 major
amputations with 11 deaths; 13 excisions of joints with 4
' D'lf conservatire Chirtm/ic dcr (riieder, Breslau, 1854.
''■ St. Gcorge\'( Hofiintal Reports, vol. i. ' Ihid. vol. viii.
* ' On Hospitalism and the Causes of Death after Operations,' 1874.
"' Brifixh Mcdiciil Journal, August, 1879.
" St. Bartliohimeir's Ho^jiital R<-pnris.
CLEANLINESS: M'VAIL. 415
deaths ; 29 cases of removal of tumours of the mamma, no
death; 13 cases of removal of tumours of the tongue, 1 death;
4 lithotomies, no death ; 32 herniotomies, 6 deaths ; 25 teno-
tomies, 1 death ; 74 operations for phimosis ; 36 cases of
fistula in ano, &c.
Among the 45 deaths were 9 from py?emia and four from
erysipelas. The causes of death in the other cases are not
given. Erysipelas attacked 17 cases operated on, and 11 others.
One very striking case is mentioned. The femoral artery was
ligatiu'ed with various aseptic precautions for popliteal aneurism.
The wound did well till the twelfth day, when haemorrhage
occm-red. It was then re-opened without aseptic precautions,
and the patient died of pyaemia.
Thus, by the use of cleanliness alone, infective diseases are
by no means banished from St. Bartholomew's Hospital. In-
deed, in considering these results, it must be remembered that
a considerable number of the cases were operated on aseptically.
How many cases were treated by good surgery and cleanliness
alone, without aseptic precautions, and with what results, we do
not know.
Very good results obtained by methods which are not very
powerfully antiseptic were published in the spring of 1880 by Dr.
McVail.^ During the preceding three years 107 operations had
been performed of which 50 were major operations. Of these 50
cases, 3 died. Among them were 31 major amputations, and
the three deaths occurred in these cases ; in one it was due to
internal injuries ; in one it followed gangrene of the back, due
to contusion ; and in one pyaemia was the cause. The onset of
the pyemia in the last case is said to have followed the open-
ing of an abscess over the sacrum, and death followed within
forty-eight hours — a very rapid course for pyaemia ! Was it
simply a case of sapnxjmia, or was the abscess part of the
pyaemia? Then there were 3 cases in which joints were
opened, viz., one compound dislocation of the elbow, which was
reduced, but the local result is not given ; one case of ex-
cision of tlic head of tlie radius, resuK not inentioned ; and one
case of excision of a metacarpal bone in which some joint was
o])ened.
' BrUitili J/rdicfi/ Journal.
416 RESULTS OF ANTISEPTIC SURGERY.
Of course these are a very small number of operations in
three years, and they were treated in a country hospital, so
that the result is not at all surprising ; but when Dr. McVail
attempts to draw extensive conclusions from them, and to
show that the method of treatment adopted in these cases is
better than the aseptic method, he is using a fallacious argu-
ment. All that can be said is that under the conditions in
which these operations were performed, aseptic treatment was
but little necessary, though even here we find that one out of
31 major amputations died of pyaemia. As we have seen, the
best surgeons, Mr. Spence or Mr. Savory for instance, even
with the use of the most scrupulous cleanliness, cannot reckon
on anything like absence of infective diseases.
After all, these statistics are not nearly so good as the
results obtained by Bardenheuer with aseptic treatment in the
Cologne Infirmary in one year.' He had no death among
133 aseptic operations involving bones. These included, ac-
cording to MacCormac —
41 amputations (17 of thigh) through bones.
10 ,, at joints (1 at hip).
53 resections (15 of hip and 12 of knee).
2H cases of removal of wedge-shaped pieces of bone.
5 operations for badly united fracture.
\ case of trephining.
' MapCormap's Antigej)tic Surgery, p. 29.
SUMMARY OF THE GENERAL RESULTS. 417
CHAPTER XVIII.
RESULTS OF ANTISEPTIC SURGERY {continued).
General considerations. Wounds of, and operations on, healthy joints. Method
of treatment adopted in these cases. Definition of the term ' Aseptic
course : ' Example. Wounds of healthy joints. Operations on healthy
joints. Objections to the value of these cases : reply. Incisions into joints
affected with synovitis. Incisions into joints affected with pulpy degenera-
tion of the s^movial membrane — a without suppuration, b with suppuration.
Volkmann's results : Max Schede : Paul Earth : Saxtorph : Piechaud :
Nussbaum : Albert : Hueter : Letievant : Kraske : Reyher : Bergmann.
Comparison of Reyher's results with those obtained during the Crimean
war, and with Heintzel's. Treatment by irrigation. Necessity for observing
the minutest precautions as showni by Mr. Lister's case. Results of removing
foreign bodies from joints without aseptic precautions: Larrey : Spence :
Paget.
So far I have been dealing with general statements; and though
these are often not of much use, yet I cannot think that there
can be any doubt as to the great value of the facts which I
have narrated. Thus, for example, we have had an opportunity
of comparing Mr. Lister's results in Glasgow before and after
the introduction of aseptic treatment. After be went to
Edinbiugh, we were able to trace a very marked improvement
following the introduction of the aseptic method; and we
also had the opportunity of contrasting the results of aseptic
treatment with those of treatment by antiseptics in Mr. Lister's
own hands. We were further able to point out that there was
a great difference between these results and those obtained
during the greater part of the same period, in the same
hospital, and under more favourable hygienic conditions, by a
surgeon who did not practise aseptic treatment.
We have fiu'ther had most striking evidence from abroad
showing that in infected hospitals the aseptic method has done
what other methods, such as the open method, treatment by
E E
418 RESULTS OF ANTISEPTIC SURGERY.
irrigation or by antiseptics, could not do. It has not only
diminished, but when properly employed, it has abolished in-
fective disease. That this result has not been simply due
to cleanliness, as has been suggested by some, is shown by
numerous facts, such as those mentioned by Nussbaum (p. 394)
and Volkmann, and also by the results of the use of thymol
(p. 404).
Nor must I forget to mention the results obtained in
ovariotomy, although these are not test cases. For the peri-
toneum has a wonderful power of destroying causes of putre-
faction, or of rendering them inert by rapidly removing the
fluid in which they might grow. Thus, dust-laden air has
been injected into the healthy peritoneal cavity without bad
results, though, if ascitic fluid were present, or if the peritoneum
were unhealthy, there would almost certainly be fermentation,
and probably, as a result of this, depending on the amount and
natm*e of the irritating products formed, peritonitis. In the
healthy peritoneum, which absorbs fluids with immense rapidity,
there is no fluid for the organisms to develop in, and thus
they are left in contact with active healthy li\dng tissue, which,
as we have seen from experiment, rapidly destroys them.
Hence the case of ovariotomy is by no means a test.
There are certain cases, however, to which I must now
allude, in which there is not the same tendency to destruction
of organisms, but where there is opportunity for them to
develop, and where the admission of septic dust is liable, as
experience has shown, to be followed by very serious conse-
quences. An example of such a case is where organisms are
admitted into a healthy joint. Here fluid is present, in which
they can develop, and here also all parts of the living surfaces
are not in contact, and, therefore, organisms may be present in
the fluid of the joint and yet not in contact with healthy living
tissues. This is, then, a test case, for here organisms, if ad-
mitted, will as a rule grow. We must therefore inquire, how
injuries which might involve the entrance of organisms into
healthy joints behave under the various methods of treatment.
Then, again, in chronic abscesses we have similar conditions.
Here the fluid is practically under the same conditions as if
it were in a flask ; the walls of the cavity are probably not even
TREATMENT OF WOUNDS OF JOINTS. 419
healthy. How do such abscesses behave under various circum-
stances ?
And lastly, although this is not such a test case, Ave know
that compound fractures, whether made by the surgeon or by
accident, are very dangerous, chiefly on account of their great
liability to be followed by infective disease. In this instance
the destroying action of the blood clot and of the living tissues
can come into play, but nevertheless the movements to which
the part, is liable are apt to interfere with their action. Blood
clot is only of use as a destroyer of bacteria if it be kept at
rest.
Wounds of, and Incisions into, Healthy Joints.
I have already published the cases which have occurred in
Mr. Lister's practice from the end of 1871 up to November 1879,'
but I shall introduce these tables here in order to complete
the subject. Before, however, discussing the results as a whole,
T must mention how the cases have been treated, and what is
the usual aseptic course.
Wounds of joints are treated on the principles described at
page 113. If the case is seen very shortly after the accident
(within a few hours) the joint is thoroughly washed out with
1-20 carbolic lotion by means of a syringe and catheter, the
wound being enlarged if necessary; the surrounding skin is
well washed with the same lotion, a drainage tube is introduced
into the joint, a large gauze dressing is applied, and a splint is
arranged so as to prevent movement. This treatment is carried
out under a spray of carbolic acid. If the wound does not
come under obser\'ation till after the lapse of twenty-four or
thirty-six hours, a solution of carbolic acid in methylated spirit
( 1 part of carbolic acid to 5 of spirit) is used. If a still longer
time has passed since the receipt of the injury, fermentation of
the fluids in the joint has generally taken place, and there is
but little hope of eradicating it. An attempt may, however, be
made by the use of either of the lotions just mentioned, or of a
solution of chloride of zinc (40 grs. to the ounce) or of iodoform
suspended in alcohol and water.
In operating on healthy joints, the various precautions
' British Medical Journal, November, 1879
E K 2
4:^0 RESULTS OF ANTISEPTIC SURGERY.
described in the chapters on aseptic surgery must be carefully
carried out. As a rule the 1-20 carbolic lotion is used for
all purposes. When the operation is concluded, a drainage
tube or a horse-hair drain is introduced into the joint so as
to provide free escape for the serum, which will probably, for
a few hours, be of considerable amount, owing to the irritation
of the synovial membrane by the manipulations and by the
carbolic acid. The drain can generally be dispensed with in
simple cases, such as after the removal of a loose cartilage, in
from one to three days. As the residt of these operations, the
discharge becomes very slight after the first twenty-four hours.
There is no pain nor swelling, in fact no local inflammatory dis-
turbance whatever, and therefore, of com"se, no suppuration.
Constitutionally the patient remains quite unaffected : he feels
well,' eats well, sleeps well, and in fact, thinks it a great hard-
ship to be kept in bed for a few days. In the following cases,
when I use the term ' aseptic course,' I mean this condition
of absence of local or constitutional disturbance.
Let me take as an example a case of recent fracture of the
patella, which was operated on with the view of obtaining bony
union.
W. T. set. 37 was admitted to King's College Hospital on
Dec. 13, 1879, suffering from a recent simple transverse frac-
ture of the patella. The accident had occurred on December 9.
Condition on admission. — The knee-joint was much
swollen and contained a considerable quantity of fluid. The
patella was fractmred transversely and the fragments were about
two inches apart. There was a good deal of pain in the joint.
Ope^'Cition. — On DecL'mber 13, chloroform having been ad-
ministered, Mr. Lister made a longitudinal incision about 4
inches in length over the patella, the various aseptic precau-
tions before described being employed. The knee-joint was of
course at once opened. A quantity of coagulated blood and
fibrous tissue filled up the space between the fragments, and
this was removed. A pair of dressing forceps was then passed
into the joint and projected against the skin at the most de-
pendent part of the outer side of the joint. An incision was
made on the projecting point, and by means of the forceps a
horse-hair drain was drawn into the joint. The fragments were
ASEPTIC COURSE.
421
then drilled obliquely, avoiding the cartilage, and, a piece of
strong silver wire being passed along the drill-tracks, the frag-
ments were firmly tied together. The two ends of the wire
were then twisted together and left of sufficient length to pro-
ject from the wound. A drainage tube was introduced into
the incision superficial to the patella and brought out of the
upper angle of the wound. The remainder of the line of in-
cision was stitched. A large antiseptic dressing was applied
enveloping the whole of the thigh, and the limb was placed
on a posterior splint. The foot of the bed was raised on
blocks so as to make the discharge flow upwards.
After-'progress. — The after-progress of this case was typical.
There was never the slightest pain or constitutional disturbance
(see Fig. 77). On the following day (December 15) the dress-
jnn
Fig.
-TEMPERATUUB chart KROM a case op operation FOPv
FRACTURE OF THE PATELLA. (No. 21, p. 434.)
ing was changed and a fresh dressing re-applied ; there was no
pain or swelling of the joint. On December 17, the dressing
was again changed, and a portion of the drain was removed
from the joint. On December 19, the superficial drain and
part of the remaining drain for tlie joint were dispensed with ;
most of the stitches were taken out. At the next dressing, on
December 24, the remainder of the drain and the rest of the
stitches were removed. On December 31, the wound was
again dressed, and was found to be quite healed, except a minute
speck, where the drain for the joint had been. This was found
to be quite healed on January 5, when passive motion was l)t gun.
The wire was removed on February 9, and bony union was
found to have taken place. WliciMlic patient was discharged
on February lo, the movements of the joint were perfect
through an angle of 45° ; patient could kick vigorously.
422
RESULTS OF ANTISEPTIC SURGERY.
I. Wounds
No.
Name nnd Age
Date of Admission,
Operation, and Dis-
charge ; with Kesult
Injury
1
Frank K., 29 .
yl(/,,Nov. 20, 1871.
Op., Nov. 20, „
Dis., Dec. 23, „
Result, cured.
Little finger-joint fractured in various places.
Skin over hand contused. Fourth meta-
carpal bone laid bare in the greater part of
its extent. Fourth metacarpo-plialangeal
joint opened.
2
George G., GO .
Ad., June 28, 1872.
Op., June 28, „
Dis., Oct. 1, „
Result, cured.
Compound comminuted fracture of the
humerus, caused by the wheel of a wagon
passing over his arm. Humerus fractured
in two places ; the lower fracture commu-
nicating with the elbow-joint. Patient
admitted about two hours and a half after
the accident.
•)
Robert H., 30 .
Af]., Mav 12, 1873.
Op., May 12, „
Bis., July 17, „
Result, failed ; ampu-
tation.
Compound fracture of the carpal bones of the
left hand. Extensive laceration of the soft
parts. Machinery accident. Patient ad-
mitted immediately after the accident.
4
Walter S., 42 .
Ad., May 17, 1875.
Op., Mav 17, „
/>/*■., May 21, „
Residt, in process of
cure.
Wound of metacarpo-phalangeal joint.
5
Francis J. ,48 .
Ad., Oct. 4, 1875.
Op., Oct. 4, „
iJis., Dee. 4, „
Result, cured.
Compound dislocation of the ankle ; the
articular surface of the tibia protruding
through a large wound anteriorly. Both
malleoli torn off.
(i
Henry W. . .
Ad., June 8. 187(!.
Op., June 8, „
Dis., June 13, „
Result, cured.
Thumb and trapezium nearly torn off, and
the carpal joints opened. Gunshot-wound.
David S., 13 .
Ad., Mav 2, 1877.
Op., May 2, „
JJis., after Mr. Lister
left Kdinl)urgl).
Result, cured.
Large lacerated wound of right knee. Large
flap of skin thrown to one side. Mud was
ground into the cartilaginous surface of the
internal condyle of i he femur. The acci-
dent resulted from a wheel of a heavy cart
passing over patient's leg.
MR. LISTER'S JOINT CASES.
423
OP Joints,
Little finger amputated ; other parts
well syringed with 1-20 carbolic lotion.
Wound injected with 1-20 carbolic lotion.
Some loose pieces of bone were removed
from the lower wound. (Xo portion
of the articular end of the humerus
was, however, removed.)
Wound injected with a solution of car-
bolic acid in rectified spirit (1 in 5).
Washed out with 1-20 carbolic lotion.
The wound was injected with 1-20 car-
bolic lotion, and an attemjit was then
made to reduce the dislocation. This
failing, the articular surface of the
tibia, was sawn off, the astragalus
being left untouched. Foot fixed at
right angles to leg.
The thumb, with its metacarpal bone,
was removed ; the trapezium was also
dissected out. The wound and the
carpal joints, as far as possible, were
injected with 1-5 solution of carbolic
acid in rectified spirit.
Shreds of tissue were clipped away, and
the cartilage of the condyle was pared
with a knife where the dirt was most
ground in. The whole of the dirty
wound was scruljbed with a nail-brush,
and I -20 carbolic lotion, and, in addi-
tion, 1-.") spirituous solution of carbolic
acid were applied. No stitches were
inserted. Tlie limb was ])laced on a
posterior splint.
Some sloughing and suppuration occurred among
the contused parts in the hand, and an abscess
formed in the forearm. Entirely healed De-
cember 23. Passive movements were begun in
December, and could be easily performed.
Putrefaction was avoided ; typical aseptic course.
The fracture had quite united on August 10.
The wound was quite superficial on August 3,
and boracic dressing was applied. On August
15, erysipelas attacked the wound. This passed
off, and the wounds were quite healed on Sep-
tember 20. When dismissed, patient was able
to flex his arm sufiiciently to enable him to
touch the shoulder of the other side.
Putrefaction occurred in spite of the injection ;
and, as fever set in, Mr. Lister operated on May
16, removing the carpus and fingers, but leaving
the trapezium and the thumb. The flaps were
left gaping,and carbolic oiled lint (1-10) was
introduced between them. Flaps brought
together on May 24. Stump was quite healed
on June 25.
Putrefaction was avoided. Treated as an out-
patient. Wound followed an aseptic course.
Aseptic course. The wound was almost abso-
lutely healed when the patient was discharged.
Joint strong and slighth' movable. The tem-
perature was on one occasion as high as 100 deg.
Aseptic course. Treated as an out-patient after
June 13. On June 31, the wound had almost
entirely healed.
The wound became filled with blood-clot, the
deeper part of which became organised. On
May 27, there was a large granulating surface.
The wound was quite superficial on June 26,
when boracic ilressing was substituted for the
carbolic acid. There was at that time very-
considerable movement of the knee-joint, with-
out pain. Li August 1878, ' patient visited the
hospital, walking without any assistance, the
two knees being equally useful, except that the
injured one was still somewhat stiff."
424
RESULTS OF ANTISEPTIC SURGEli^
I. Wounds
Kame and Age
Ellen M., 12
Jane D., 50
Date of Admission,
Operation, and Dis-
charge ; with Result
10 Maria L., CO
Henry B., 22 .
12
Samuel M., M
ArcliiljMl.lK., lU
Ann P., 08 .
Ad., Nov. 6, 1877.
Op., Nov. (!, „
Dis., Nov. 17, ,,
Result, cured.
Ad., Oct. 1.5, 1878.
Op., Oc-t 15. „
Dis., June 20, 1879.
Result, wound of
joint cured.
Ad.,'Sov. 12, 1878.
Op., Xov. 12, „
I)is.. April 19, 1879.
Result, in process of
cure.
Ad.. April 20, 1879.
0/j., April 21, „
Dis., May 30, to coir'e
as out-patient.
Result, cured.
Ad., Julv 8, 1879.
Op., Julv 8, „
iJis., Juiy 24, „
Result, cured.
Ad., Dec. 10, 1880.
Dis., Dec. 24, „
Result, cured.
Ad., Aufi;. 11,1881.
0/A, Aug. 12, „
Dis., Aug. 30, „
Result, cured.
Injury
Punctured wound of ankle-joint, caused by
scissors. The accident happened twenty-
one hours before admission. Glairy fluid
escaped, and a probe passed into the joint.
Foot red and swollen.
Compound fracture of the lower end of the
femur, with splintering of the condyles into
the joint. Patient was seen one hour and
a half after the accident. (See compound
fracture. No. 70.)
Compound dislocation of the left ankle-joint,
with comminuted fracture of the fibula and
fracture of the internal malleolus. Skin in
the neighbourhood of the wound much
contused.
Patient jumped over Waterloo Bridge ; in
his descent, he struck hi.'i left elbow against
the side of the parapet. The result was an
oblique fracture into the elbow-joint, de-
taching the internal condyle. There was a
small opening in the skin communicating
with the fracture.
Punctured wound of the left knee-joint, just
above the patella. The finger, when intro-
duced into the wound, passed into the joint,
and felt the under surface of the patella.
Synovial fluid escaped. Great pain on
movement of the joint. The wound was
inflicted about fourteen hours before the
patient came to tlie hospital.
Incised wound of knee-joint. Incision one
and a half inch long.
Compound fracture of the olecranon. The
accident happened on August 10. and was
iunnediately seen by the house surgeon.
J
MR. LISTER'S JOINT CASES.
425
OF Joints (continued).
Treatment
Wound enlarged, and joint injected with
a solution of carbolic acid in spirit
(1-5). ■
The opening in the skin was eulari^ed.
The projecting end of the femur was
sawn off, and reduction was effected.
The wound was washed out with 1 to
20 carbolic lotion. An incision was
made into the knee-joint on the outer
side, and a drainage-tube was inserted
into it, to prevent accumulation of
huid.
The detached portions of bone were re-
moved; wound syringed out with 1-
20 carbolic lotion. Dislocation re-
duced. Drainage-tubes inserted. Du-
puytren's splint.
Wound enlarged ; some sm.-jll fragments
of bone removed, and the wound and
joint syringed out with 1-20 carbolic
lotion. Drainaije-tubes inserted.
Joint wa-shed out with 1-20 carbolic
lotion, and witli a solution of carbolic
acid in rectified spirit (1-5). Drainage-
tube inserted; posterior splint applieit.
Wound sjTinged out with an emulsion
of eucalyptus oil containing iodoform.
Surrounding parts washed with 1-20
carbolic lotion. 'I'ube introduced into
the joint.
On the lOtli the wound was thoroughly
washed out with 1-20 lotion anU
treated a^eptically. As there was no
bed, patient could not be admitted till
the following day. On the 12th the
wound wa.s again washed out, and, the
opening being enlarged, the fragments
were brought to;rethcr by means of
strong silver wire. l)rainage-lul)e
inserted, wounil stitched, straight
splint applied anteriorly.
The wound had quite healed on November 17.
Aseptic course ; dressed four t>mes. When pa-
tient was discharged, the ankle was quite nor-
mal, with perfect movement. (See Chart I.)
Aseplic course. The drainage-tulie was removed
from tlie joint on October 28, and the wound of
the joint had completely healed on November
21 : the wound in the thigh healed on December
13. As the fracture remained ununited, Mr.
Lister injected iodine between the ends of the
fragments on February 14. Union not yet oc-
curring, Mr. Lister cut off the ends of the bones
and wired them together with thick silver wire.
The femur is still ununited, but is under treat-
ment. (See (yhart IL)
Aseptic course. Some portions of the skin
sloughed. When discharged, the wound was
almost healed, but the ankle-joint was stiff.
Aseptic course. Wound completely healed on
June .^0. The movements of the joint were
then very good, and have since that time
steadily improved. (See Chart III.)
Aseptic course. The pain on moving the knee
ceased a i'ew hours after it had been washed out.
The wound was quite superficial when the pa-
tient was discharged, an 1 the knee was quite
movable. Healing was complete on .July 31.
The patient was again seen in October, the
movements of the knee being then perfect.
Typical asejitic course. Tube removed on Decem-
biT 17. When discharged the wound had
almost entirely healed, and healing was com-
plete in a few days. Knee-joint perfectly
movable and leg quite strong.
Aseptic course. Some of the stitches were too
tight and caused a little irritation, but this
subsided as soon as they were cut. Incision
healed and stitches removed on .August 16.
Orains entirely removed on August 19. The
wound liad (|uite healed when the patient was
dischargeil. (The ends of the wire which
brought the fragments together were cut short,
and the cutaneous margins were brought to-
gether over I hem, so that the wire reuuiins.)
Seen in middle of September — extension per-
fect. l'"le.\ion beyond a right angle, and can be
<lone perfectly by passive motion. Arm gain-
ing strength.
426
RESULT !S OF ANTISEPTIC SURGERY.
II. — Operations on
No.
Name and Age
John C, 46
David B., .39
John lilcl., M .
.John H. 19
William T., 31.
France."* G., 54
Date of Admission,
Operation, and Dis-
cbarge ; with Result
Ad., April 5, 1872.
Op., April 6, „
Dis., May 9, „
Result, cured.
Ad., Julv 22, 1872.
Op., July 22, „
Dis., Aug. 5, „
Besult, cured.
Ad., March 13, 1873,
Op., March 28, „
Dis., June (>, „
Result, cured.
Ad., May 6, 1873.
Op., May 31, „
Dis., Aug. 15, „
Residt, cured.
^rf., Xov. 19,1873.
Op., Nov. 26, „
Dis., Jan. 8, 1874.
Result, cured.
Ad., Xov. 3, 1873.
Op., Feb. 8, 1874.
Dis., Sep. 14, „
ResuH, improved.
Caries of metacarpal bone and first phalanx
of ring-tinger.
Loose cartilage in knee-joint.
Ununited fracture of olecranon ; fracture ob-
lique ; considerable separation of frag-
ments. Patient unable to extend the arm.
Accident occurred five months previously.
Dislocation of the lower end of the ulna
backwards. The lower end of the radius
was much thickened. Suppuration had
occurred in the sheaths of the flexor ten-
dons. The movements of the wrist-joint
were painless, but limited, more especially
as regards extension.
Loose cartilages in the elbow-joint. The
movements of flexion and extension were
impaired, more especially tlie foimer.
Pain on attempting to complete these
movements.
Ununited fracture of neck of right femur.
Accident happened IS months before ad-
mission. Right limb, 29| in. ; left limb,
31^ in. Suffered great pain; could nei-
ther sit nor walk.
MR. LISTERS JOINT CASES.
427
Healthy Joints.
Remarks
Removal of the finger and the whole of
the metacarpal bone ; the carpal arti-
culations being of course opened.
Free incision into joint ; cartilage re-
moved.
Longitudinal incision over olecranon,
the cartilaginous end of the humerus
being at once freely cxpised. Ends
of fragments refreshed, drilled, and
tied together by strong silver wire.
Wound left open. Splint applied so
as to keep the arm extended.
Abscesses opened; end of ulna removed ;
drainage-tube introduced into the
■vvrist-joint, which was healthy.
Longitudinal incision over externa) con-
dyle. Joint opened ; loose bodies
(about 200 in number) scooped out.
Two drainage-tubes were inserted ;
wound stitclied.
The limb having been drawn down to
full length bj' pulleys, an incision was
made over and above the trochanter,
and the ends of the fragments were
refreshed with the gouge and hammer,
the joint being opened in the process.
Drainage-tul)(!s inserted into joint;
no stitches ; long splint aiul exten-
.sion with weight and pulley apjilied.
Length of right leg after operation,
30^ in.
On April 23, the wound had entirely healed ex-
cept a small point at the distal end. Aseptic
course.
Wound Avas completely healed on August 5. It
had been dressed four times. Aseptic course.
Knee freely movable.
The wound had completely healed on May 2, ex-
cept where the wire projected. Dressed ten
times. Wire removed on May 19, when union
was complete. Passive motion was commenced
on April 8, and was performed at each dress-
ing. Typical aseptic course. When dismissed,
the movements of the arm were almost perfect.
In a letter received from the patient some time
afterwards, he stated that the one arm was as
good as the other. The temperature in this
case was irregularlv taken but it was only
once above 100° F., and then it was 100-6° F.,
an evening temperature.
Xo local or constitutional disturbance followed
the operation. When sent to the convalescent
home on August 15, there was still a small
sinus, but this soon healed. The movements of
the wrist-joint were greatly improved.
Healed on December 17. Dressed seven times.
Aseptic course. Arm was paralysed at first,
owing to the pressure of the tourniquet ; but,
under the use of galvanism, this was cured.
When dismissed, the movements were much
improved. (See paper by Mr. Sampson Gam-
gee in Lancet for January 10, 1871.) The tem-
perature in this case was only taken once daily,
and was only once above 99° F., viz. on the
7norning after the operation, when it was 99*7°
F.
Healed on March 28 ; aseptic course. Extension
was maintained till April 3 ; but when it was
at length removed, it was discovered that the
weight had been too heavy, and that the limb
operated on was longer than the other.
VVhcn the patient left the hospital, there was
not osseous union, but she was al)le to walk
fairly and sit. and the pain which she jirevi-
ouslv sull'ered had comiiLetelv disappeared.
(See Chart iV.)
428
RESULTS OF ANTISEPriC SURGERY.
II. — Operations ox
No. Name anil Age
Graces., 15
10
Agrcs
Edward R., 59 .
Alexander — , 26
11
12
James D., KJ
John D., 64
Date of Admission,
Operation, and Dis-
charge ; with Result
Ad., Maj- C, 1874.
Op., May 14, „
Dis., May 27, „
ResiiU, cured.
Ad., Jnlv 1875.
0/>., Jiilv 13, 1875.
Dis., Oct. 20, „
Result, cured.
Ad., Aug. 12, 1875.
Op., Aug. 17, „
Dis., Dec. 16, „
Result, cured.
Ad., Xov. 10, 1875.
Op., Nov. 16. „
Dis., Dec. 26, „
Result, cured.
Ad., Feb. 14, 187
Op., Feb. 14 „
Dis., Mar. 20, „
Result, cured.
Ad., May 18, 187
Op., June, 1 ,,
i>is., Sept. 8, „
Result, much
proved.
Disease
Ganglion on the back of both wrists beneath
the extensor tendons, which had resisted
all treatment; multilocular.
Ostitis of the tibia; bone much thickened.
A sinus was present, leading down to bare
bone.
Enchondroma of scapula. A tumour had
been removed from the same region seven
years before the patient's admission to
hospital.
Four months before admission, patient met
with an accident, causing fracture of the
ulna a little above its middle, and disloca-
tion of the head of radius backwards. Pro-
nation and supination were almost impos-
sible. Extension could be carrieil slightly
beyond a right angle.
Patient was run over immediately before
admission. Left ankle much bruised and
distended with effused bloed.
Rupture of rectus fenioris and crureus in*
both thighs, the vasti being still attached
to the sides of the patella. No power of
extension ; though, if the leg were ex-
tended, it could l)e kept so. If it became
at all bent, the patient fell.
MR. LISTER'S JOINT CASES.
Healthy Joints {continued).
429
Treatment
Both ganglia were removed, the ten-
dons being exposed during the opera-
tion and held aside. On the right
side the wrist-joint was opened, the
articular surfaces of the scaphoid and
radius beinor seen.
Thinking that the case was one of ne-
crosis, Jlr. Lister cut down and gouged
out a portion of the bone. In doing
so, he found the interior of the shaft
softened, and converted into a sort of
granulation material. In fcraping
out this matter, the gouge accident-
ally passed into the ankle-joint, which
was healthy. Chloride of zinc was
applied, and a drainage-tube inserted.
The whole of the scapula below the
spine, the spine itself, and about (^ne-
third of the glenoid cavity were re-
moved, the upper border of the sca-
pula and part of the glenoid fossa be-
in^ left.
Jixternal lateral ligament of the elbow-
joint divided and head of radius snip-
ped off. DraiiiaKC-tubc inserted into
joint. Xo stitches.
Joint incised and clots evacuated.
The vasti wore detached from the sides
of the patella. The upper border of
the patella was rawed, and the vasti
were stitched to it-r-a V-shaped por-
tion being taken out of the rectus and
crureus. Couiiter-ojienings made on
each side of the joint and drainage-
tubes inserted. Only one knee opera-
ted on.
Remarks
When dismissed to be treated as an out-patient
healing was not complete. On June i', the left
wrist was found healed; on June 7, the rii^ht
had also healed. Left dressed seven times ;
right eight. Drainage-tubes removed Mav 20.
Typical aseptic course. Movements of fingers
and wrist-joints on both sides were perfect.
Temperature irregularly taken. Highest tem-
perature was 99'5^ F.
When the patient was discharged, the wound had
completely healed. There was no pain, and the
ankle-joint was freely movable. No constitu-
tional or local disturbance followed the opera-
tion.
A iwrtion of one of the flaps lost its vitality, leav-
ing a lar^e deep hole, at the bottom of" which
the articular end of the humerus could be seen.
This took a long time to fill up, but was com-
pletely healed when the patient was discharged.
The rest of the wound healed bv first intention.
Passive movement was kept up, and when the
patient was dismissed, there was good move-
ment at the shoulder-joint. (See (^.hart V.)
He.aling was complete on Deceml)er 8. Dressed
six times ; aseptic course. Passive movements
were begun on November 18. When dis-
charged, the movements in all directions were
verj' fair. When seen again in September 1877,
all the movements were almos*; absolutely per-
fect.
Aseptic course. On March 10, the wound was
quite superficial, and boracic dressing was ap-
jiliud. Movements of joint normal.
Wound went on well for about three weeks, when,
owing to the patient pushing his band under
(he dressings, the wound putrefied ; l)ut by this
time the opening into the joint had dosed, and
no harm resulted. When dismissed, the pa-
tient could exteml his knee after it had been
bent to an angle of 13.5= ; and the other knee
being kept c.Nteiided by means of a sjilint, lie
could walk withmit fear of falling. (Sec report
of case by Dr. Roxburgh in LunccL 1878")
(See Chart VI.) ^
430
RESULTS OF AXTISEPTIC SURGERY.
II. — Opkrations on
Name and Age
13
Adam W., 7
14
15
William T., 35
(See No. 5.)
Frauds S., 40
1(!
John S., o
Date of Atimission,
Operation, and Dis-
charge ; with Result
Ad., Mav '27, 1877.
Op., Julv 6. „
Dis., Auk- 24, „
Result, cured.
.4(7., July 19, 1877.
Op., Julv 25, „
Z>is., Auk. 11, „
Result, cured.
Ad., Oct. 24, 1877.
Op., Oct. 20, „
i>/s.. Jan. 11, 1878.
Result, cured.
Ad., Feb. 6, 1878.
Op., Feb. G, „
JJis., Mar. 29, „
.Result, cured.
Badly united fracture of tlie lower end of the
liumor\is, the lower part of the upper frag-
ment pmjectiuff backAvards and locking
the olecranon, thus causing inability to ex-
tend the forearm beyond an angle of 120°.
Of some months' standing.
Return of previous symptoms.
Transverse fracture of the right patella, pro-
duced by striking the bent knee against a
bar. Patient was admitted on October 1 2,
but insisted on going home, and on being
treated by apparatus. As the apparatus
did not answer, he now readily consented
to the performance of the operation pre-
viously proposed.
Htcmophilia, with elTusion of blood into the
right ankle-joint. Stated that he was
kicked on the ankle three days before ad-
mission. Patient -was suffering great pain
and constitutional disturbance. The joint
was tense from the presence of fluid, and,
as Mr. Lister feared that suppuration
might ensue, he incised the joint.
MR. LISTERS JOINT CASES.
Healthy Joints (contimted).
431
Two longitudinal incisions made on the
posterior aspect of the joint : one be-
tween the external condyle and the
olecranon, the other between the ole-
cranon and the ulnar nerve ; these in-
cisions, of course, opening the articu-
lation. The projecting portion of the
humerus was then removed, the at-
tachment of the triceps to the olecra-
non process bemg left intact, and a
hollow was gouged for the reception of
the olecranon process. In order to get
complete extension, it was necessary
to remove the whole of the external
condyle ; drainage-tubes inserted.
Elbow-joint opened ; no loose cartilages
found, but a number of bodies at-
tached to a fringe of synovial mem-
brane were removed.
A longitudinal incision about three
inches in length was made over the
patella, when it appeared that the
fragments were mutually displaced,
and a mass of firm coagulum, mixed
with fibrous tissue, interposed between
them, so that it would have been im-
possible to bring the osseous surfaces
into contact except by operative means.
This material -was removed, and tlic
ends of the fragments were then re-
freshed, drilled obliquely and tied to-
gether with strong silver wire. An
opening was made into the joint on
the outer side for the introduction of a
horsehair-drain. The wound was
clo.scd by stitches, and the limb phiced
on a ]iosterior Gooch's splint.
An incision was made on each .side of
the ankle-joint. A qujintity of dark
fluid blood escaped. Horsehair-drain
passed through the joint.
Remarks
The -wounds had quite healed on July 30;
dressed six times; typical aseptic course.
When discharged, the movements of the elbow-
joint were almost abbolutely perfect. fSee
Chart VII.) ^
Aseptic course. Wound had healed, and the
movements were restored when the patient was
discharged. (See Chart VIII.)
The wound had completely healed on November
17, except where the wire was. Drain removed
from knee on November 4. Incision on outer
side of knee healed on November 11. Dressed
seven times ; typical aseptic course. Wire was
removed on December 21. The splint was left
off on January 7. Patella firmly united. There
was naturally considerable stiffness of the knee,
owing to the limb having lain so long in the
splint, but it could be moved with ease through
an angle of about 45 deg. Patient would not
submit to forcible movement under chloroform,
or even to wear an elastic apparatus for gradual
flexion. (See Chart IX.)
Both wounds had healed on March 22. Ha-mor-
rhiige occurred from one of the wounds on the
morning after the operation, and recurred at
intervals during three days, being at length
checked by the application of a solution of per-
chloride of iron in glycerine. Wounds were
quite superlicial on March 12, and l)oracic
dressing was therefore applied. No sujipur-
ation ; asejitic course. When discharged,
there Avas no pain in the joint: the joint was
quite movai)le, and the boy was able to run
about. Patient was in liospital in September
1879, on account of bleeding from his linger;
the ankle was then in everv respect q"uile
normal. (Sec Chart X.)
432
RESULTS OF ANTISEPTIC SURGERY.
II. — Operations on
No.
17
Name aud A.ge
William B., 45 .
Date of Admission,
Operation, and Dis-
charge ; with Result
,4rf., March 18,1879.
Op., March 20, „
J),s., May 4, „
Result, cured.
18
Edward W., 12
Ad., .Tan. .5. 1879.
Op., Jan. lb. ,.
Dis., June 12, „
Result, in procesa of
cure.
Ununited fracture of the olecranon of nine
weeks' standing- Patient could only ini-
liertectly extend his furearm. The frac-
ture Avas oblique, and, on flexion, there
was considerable separation of the frag-
ments.
Badlv united fracture of the lower end of
the humerus, with dislocation of both
bones of the forearm backward. Accident
happened three months before admission.
The movementa of the elbow-joiut were
very limited.
19
James P., 34
vld.jMarch 19,1879.
Op., March 24, „
Dis., April 2.5, „
Result, right cured ;
left in statu, quo.
Loose cartilages in both kuw-joint?
MR. LISTERS JOINT CASES.
Healthy Joints (conttnued).
4:53
Treatment
An incision was made on the ulnar side
of the postHrior surface of the olecra-
non. Ends of fragnients were re-
freshed with a chisel and hammer, the
joint beini{ of course opened. Fraij-
ments were then drilled obliquely and
ti'-d tofjether with strong silver wire.
Horsehair-drain passed into joini.
Wound stitched ; arm placed on a
splint in the extended position.
On the supposition that the case was
simplv one of fracture, a longitudinal
incisiiiu was made behind the joint,
with the intention of excising it ; but
the true nature of the ca.se being re-
vealed, it was detennined to avoid in-
terference with the bones of the fore-
arm. A small slice was sawn away
from the lower end of the humerus,
which was greatly distorted and thick-
ened by callus. The lower end of the
humerus was then pared and shaped
with chisel and gouge, so as to re-
semble the natural form of the articu-
lar end of the bone, hollows being
gouged for the reception of the coro-
noid and olecranon processes. The
dislocation was then reduced ; drain-
age-lubes inserted, and wound stitched.
The reason for preferring this opera-
tion to complete excision was to avoid
the lagging behind in growth of the
forearm and hand, which is so apt to
occur after that operation in young
children.
Having fixed the cartilage in the right
knee. Mr. Lister cut down and re-
moved it. Drainage-tube y)ut into
joint. Two days afterwards, a free
incision was made into the other joint,
in search of a very small loose cartil-
age, which could not be fixed, but
which the patient could generally
bring by his own manipuftitions to
the spot incised. Protracted mani])u-
lations on his own part, carried out
under the spray with carbolised liands,
failed however to bring the body to
the wound; nor could it bcdiscovcrHd,
after a long search, with the linger
and hooks.
Remarks
The wound had entirely healed on April 9, ex-
cept where the wire was. Typical aseptic
course. Drain and stitches were removed on
March 27. Passive motion was begun on
March 31 ; wire removed May 11, the union of
the fragments b?ing then complete. When
discharged, he was able to extend his arm al-
most completely. In a letter received from
him in October 1878, he stales that his arm is
almost as useful as the other, and that he can
carry on his trade as a plasterer, which he could
not do before the operation. (See Chart XI.)
Aseptic course. Passive motion was begun on
the day after the operation. Pronation and
supination were perfect from the first, and al-
ways continued so. Owing to the movements,
a sore remained over the olecranon till April
10, when it had completely healed. Tlie limb
was very strong. The movements of extension
and fiexion were fair, and were constantlv im-
proving when the patient was discharged.*
Eo'h wounds followed an aseptic course. Drain-
age-tultes remove] fr mi eacii the dav after the
ojieration. Kight knee healed April 12 ; left
knee h.ni li-aled bef.ire the patient left the iios-
pital. Mo veil. cuts on both sides unimpaired.
F F
434
RESULTS OF ANTISEPTIC SURGEBY.
II. — Operations on
Name and Age
20
Andrew G., 28 .
21
William T., 37 .
22
James K., 29
23 1 .Tosepli R., 24
Date of Admission,
Operation, and Dis-
ch irge ; with Result
Ad., June 6, 1879.
Op., June 6, ,,
2>is., July 11, „
Result, cured.
Disease
Ad., Dec. 13, 1879.
Op., Dec. 15, „
Dis., Feb. 15, 18S0.
Benult, cured.
Ad., April 10, 1880.
Op., April 12, „
Dis., Sep. 25, „
Result, stiff knee.
Ad., Sep. 27, 1880.
Op., Oct. 22, „
(See No. 25).
Patient was a medical man. He had suffered
from bunion, beside the metatarso-phalan-
f^eal joint of the great toe of the right foot,
for 14 years. Pads, etc., had been used,
but without effect. Patient was unable to
walk even short distances without great
pain, and he could not enter on the prac
tice for which his medical education had
now qualified him.
Recent simple transverse fracture of the
patella. The accident happened on Dec. 9.
Loose cartilage in the left knee joint.
I
Ununited fracture of the patella of several
months standing. Upper fragment pretty
firmly adherent to the anterior surface of
the femur. Lower fragment very small
Patient cannot walk at all.
MB. LISTERS JOINT CASE'S.
Healthy Joints {continued).
435
Treatment
Mr. Lister made a loii<ritudinal incision
over the inner side of the joint on the
dorsal nspeet. Tlie joint was opened,
and the projecting inner end of the ex-
tremity of the metatarsal bone cut off.
The remainder of the joint left intact.
Drainage-tube inserted ; no stitches.
See description of operation, p. 420.
The cartilage was removed by a free in-
cision, and a drainage-tube was in-
serted into the joint.
Longitudinal incision over the front of
the joint, tipper fnigment detached
from the femur. Ends of fragments
refreshed and tied together with silver
wire. Drainage as in the former
cases.
Remarks
Aseptic course. Wound was quite healed on
July 9. When discharged, the joint was quite
movable and the swelling from thickening of
the soft parts much less. In a note received
from him on September 16, 1879, patient
Avrites: 'The prominence on the inner side of
the foot has entirely disappeared, and I have
perfect use of the joint, with entire absence of
pain. I can walk ten miles without any in-
convenience,' (See Chart XIL)
Typical course. See p. 420. When the patient
was discharged the movements of the knee-
joint were perfect through an angle of 45°, and
were daily improving. Patient could kick
vigorously. (See Chart XIIL)
On the evening of the day of the operation the
knee was very painful, and there was so much
discharge that it was necessarv to change the
small dressing which had been applied at the
time of the operation. On the following morn-
ing the temper.iture w,is up to 102-8^F., the
knee was swollen and verv painful, and' the
dressings were saturated with discharge. There
was a blush of redness around the wound. The
discharge had no smell. This state of matters
got worse, the temperature went still high3r.
and for several days varied between 101° and
103-6°. The discharge from the joint became
purulent and an incision was made on the outer
i-iile of the patella into the joint. An abscess
formed in the thigh, and was opened. During
May matters began to improve, and gradually
the discharge diminislied and the various
wounds closed. All had healed on September
25. The knee was almost stiff, but it was
possible to get slight movement (fibrous anchy-
losis). The patient was advised to return in a
month to have the adhesions broken down, but
he did not do so. (See Chart XV.)
Aseptic course. Stitches removed on October 25.
The wounds h-id completely healed on November
4. On November 20 the patient wa.s put under
chloroform, and an attemjit made to bend the
limb. The upjier fragment had, however
again become adherent to the femur, and in
attempting to bend the limb the wire broke,
and the fragments became separated. The case
was re-opcr.ited on on November 26 (see No. 25)
(See Chart X I V.) ^ ^■
F F 2
436
RESULTS OF ANTISEPTIC SURGERY.
II. Operations on
Name and Age
24
Martha F., 43
'25
Joseph R., 24
26
Date of Admission,
Operation, and Dis-
charge ; with result
William G., 62.
Ad., Nov. 5, 1880.
Op., Nov. 12, „
Result, cured.
See No. 23.
Oo., Nov. 2G, 1880.
Bis., Feb. 5, 1881.
Result, cured.
Ad., June 21, 1881.
Op., June 24, 1881.
IJis., Aug. 11, 1881.
Result, cured.
Fracture of patella of eight weeks' standing.
Patisnt walks with great difficulty and
with the aid of sticks.
See No. 23. Refractured patella.
Recent fracture of patella,
pened on June 21.
Accident hap-
MR. LISTERS JOINT CASES.
Healthy Joints {continued).
437
Operation
Operated on in the same manner as the
, others A drainage-tube used for the
joint instead of a horse-hair drain.
Re-operated on as before. No drainage
of the joint was necessary. Wound
left open in part.
Treated like No, 21.
Eemarks
Aseptic course. No pain, inflammation or con-
stitutional disturbance. Drainage-tubes re-
moved November 16. Almost healed on Novem-
ber 22. Quite healed on November 27. Seen
on May 31, 1881. Could then walk comfortably
without a stick, could raise the leg from the bed
and flex the knee, but the flexion could not be
carried quite to a right angle, (See Chart
XVI.)
Aseptic course. On December 8 everything had
healed except a small part of the gaping inci-
sion where blood-clot filled the wound. On
scraping away the superficial laj'er of this clot,
cicatrisation was found to have advanced con-
siderably beneath it. Seen in April 1881 ; could
walk comfortably with a stick. Could not raise
leg from bed, but was able to bring it forward
in walking. Flexion gradually improving.
Union of fragments good ; no separation. (See
Chart XVII.)
Aseptic course. On the morning of the 24th (be-
fore the operation) the temperature was 100-2O
in the evening 100-6°. On the 25th T. M. 100°,
E. 100° ; dressed. 26th, T. M. 100-2° E., 98-6°;
dressed. The drain was not acting very well,
which probably accounts for the continued
elevation of temperature on the 25th ; as soon
as that was put rig-ht the T. fell. On the 27th
T. M. 99-4°, E. 100-4°. On the 28th T. M. 99-8,
E. 99-G. On the 29th tube left out. Dressed
again on July 6. Almost entirely healed and
spray stopped on July 9. A minute spot un-
healed on July 15. The temperature after the
28th ranged between 98-8° and 99-8°. Passive
motion could be readily performed without any
pain.
Tejji'kkatuke Chakts of Mk. lisTKKs Cash
TITT
_Z7F
JO"
Y\'l
'XV n
w-tmmtmvmvm\m.y;mam\-mr\wm.vmkiM
fcWyi,^J:*a.W.M.l:Hl
!■■■■■■!
F WOUNUS or, ANIJ Ol'EKATIONS ON, JoiM'S.
'-'■■■■■■■■■■I
■■■■■■■■■■■
■■■■■■■■na
...JHflHBHaHm
440 RESULTS OF ANTISEPTIC SURGERY.
The result, then, is that Mr. Lister has since the end of
1871 treated conservatively in hospital 40 cases of injuries of
healthy joints without a death, and in only one case (wounds
of joints, No. 3), was there any necessity for further operation.
This was a case of wound of joint not made by the surgeon.
In only one case in which the joint was opened by Mr. Lister
did suppuration occur (No. 22), and here, as I shall presently
shew, the aseptic method had been imperfectly carried out.
It has been objected to these cases by Mr. Bryant,' that an
equally good series of cases might be found in the case-books
of any hospital. It may indeed be that in some instances
equally good results have been obtained, but I venture to affirm
that no hospital case-book, recording cases not treated asepti-
cally, would show that all the cases treated in succession had
like results. It is as an integral record of a number of cases
in succession rather than as a record of each individual case
that these facts are important. There will no doubt be found
throughout the journals isolated examples of remarkable
results after injuries of joints, but then only the successful
cases are published ; we do not have a record of all the cases
in the practice of a particular surgeon ; we do not hear of the
many cases where failure occurred, or where conservative treat-
ment was not attempted. Then, again, the cases ordinarily re •
corded in journals have not been treated in the same way as Mr.
Lister's. For Mr. Lister not only makes an incision into a
joint, but he purposely keeps the communication open for some
days by means of a drainage tube, and he does not syringe out
the joint with any antiseptic solution. I do not believe that
such a thing could be done with a poultice or other septic
dressing without the occurrence of suppuration in the joint,
and yet among JNIr. Lister's 26 operation cases this only hap-
pened in one instance, and in it, as I shall presently point
out, we have complete evidence that the requirements of the
method had not been efficiently complied with.
jNIr. Bryant also expressed his astonishment that IMr. Lister
should regard the removal of foreign bodies from joints as a
perfectly safe procedure on the evidence of 3 cases. But then
it must be remembered that every case in which a joint was
' MacCormac's Antiseptic Surgery.
MP. BRYANT'S OBJECTIONS TO THESE CASES. 441
incised, for whatever purpose, proves the assertion that they
may be opened for the removal of foreign bodies, and so at
the time when Mr. Bryant spoke the evidence rested, not on
3 published cases, but on 20 cases of operations and 12 cases
of accidental wounds, i.e., not on 3 but on 32 cases. And in
reality it rested on many more, for this record only represents
Mr. Lister's practice since the end of 1871. For five years
previously Mr. Lister had been operating on joints in hospital
with success, and the details of some of these cases have been
published. And in private practice, also, during all these
years Mr. Lister has performed a number of operations on
healthy joints. Further, during the same time, many of Mr.
Lister's pupils had performed similar operations with similar
successes. Thus the evidence in support of INIr. leister's
statement is sufficiently ample to justify it.
It was further stated by Mr. Bryant, that a number of these
cases were too trivial to be of value, but I venture to doubt the
force of this argument. For I do not suppose that an incision
into a car]>al articulation will be regarded as a very trivial matter,
and we have in the list only 3 cases where small joints were
opened. ■ But I do not regard wounds of phalangeal joints as
such a very trivial injury after all. The cases of compound
dislocation of the phalanges which I have seen treated conser-
vatively but septically have almost all died. It may be that
I have had an unlucky experience, but I have seen that ampu-
tation is in the great majority of cases performed for these
injuries, and that where they are treated conservatively and
without aseptic precautions a great risk is run. The only case
of wound of a small joint not treated aseptically which has
occurred to my knowledge at King's College Hospital during
the last four years died of tetanus.
In speaking of ovariotomy I have said that it was not a test
case, because the peritoneum absorbs fluid so quickly that the
bacteria, if admitted, have no fluid in which they can develop ;
and 1 also added that the test case would be where there was
•ascites as well as an ovarian tumour, where, therefore, there
was fluid in which organisms may devclo]). Such cases have
always been regarded as particularly unfavourable for o})eratiou,
4J2 RESULTS OF ANTISEPTIC SURGERY.
though surgeons do not as a rule seem to have understood the
reason of this. A corresponding condition may be got in the
case of joints, more especially in the knee joint in hydrops
articuli. The ordinary practice in such cases, if they refuse
to yield to the ordinary methods, is to remove the fluid by as-
piration. That practice has been found to be perfectly safe ;
it is a subcutaneous, in fact an aseptic, operation. In Edinburgh
in 2 cases of this kind (chronic synovitis), Mr. Lister made in-
cisions into the joints and introduced a drainage tube. In
neither case was there the slightest bad result. In the first
case the drainage tube was removed on the fourteenth day, and
the wound healed a few days later. In the second case the
drainage tube was kept in a few days longer, and the wound
had completely healed in five weeks. In both instances the
disease was cured ; in both the movements of the joint were
perfect ; in neither was there any suppuration, inflammation
or constitutional disturbance. In King's College Hospital Mr.
Lister has made incisions in 3 cases of acute synovitis verging
on suppuration, and in all cases with cure without suppuration.
In these cases the knee-joint was affected. In 2 the move-
ments were good when the patient left the hospital. In the
other movement is perfect, but the leg is kept in a silicate
apparatus, as the ligaments have not yet regained their firm-
ness, and the limb is apt to become over extended. (In this
instance the inflammation was much more extensive, affecting
the adjacent portions of the tibia and fenmr and producing
softening of the ligaments.)
Then I must mention, that Mr. Lister's practice in cases of
synovial disease of joints where the disease progresses in spite
of rest, counter-irritants, &c., is to make free incisions into the
joints, and introduce drainage tubes into them. This is done
at once, without waiting for the formation of abscesses, in
cases where the disease is progressing. In 16 cases so treated
since 1871 no pus was present, and of these 16 cases 11, or
68*7 per cent., were cured without any further treatment (ex-
cision or amputation), and there never was any suppuration
from the joint. In several of the cases considerable move-
ment was obtained.
The cases were : —
12^ VISIONS INTO DISEASED JOINTS. 443
8 incisions into the knee-joint — no pus — 7 cured without further operation
4 „ „ tarsus „ 2 „ „
2 „ „ elbow „ 2 „ „
2 „ „ wrist „ 0 „ „
None of the cases died.
Then, as I have said, where suppuration has occurred, the
joint is also, in the first instance, simply incised and a drainage
tube inserted ; if necessary, further measures can be resorted
to afterwards. Of 48 abscesses of joints so treated 27, or 56*3
per cent., were cured without further operation ; and in these
there was no more formation of pus after the incision.
These cases comprised : —
1J» abscesses of the hip-joint— 13 cures without further operation — 1 death
1 „
1 ..
11 »
)>
knee
5
6
»>
tarsus
3
2 „
»
shoulder
1
o ,,
>»
elbow
1
7
„
wrist
4
There were three deaths, all of them from tubercular
meningitis, confirmed on post-mortem examination. One other
case not included here must be mentioned. A patient, a little
child, was admitted into King's College Hospital with pyaemia
after scarlet fever. Abscesses were present in various joints,
and as they were causing him considerable pain, they were
opened. The child died two days later.
Thus, taking all the cases together, we have 109 instances
where joints, healthy or more or less diseased, were opened
and drainage tubes inserted ; and of these 109 cases only 3 died,
the cause of death in each instance being quite independent of
the method of treatment adopted.
Leaving Mr. Lister's practice we find records of a number
of wounds of joints in the practice of other surgeons.
Volkmann, in his first report, mentions the occurrence of
7 wounds of joints and 2 incisions into joints for loose carti-
lages without a death. In his last report he adds 24 cases of
penetrating wounds of joints making in all 33 cases, distributed
as follows, without a death.
444 RESULTS OF ANTISEPTIC SURGERY.
Cases Deaths
Knee 15 0
Wrist 8 0
Elbow 5 0
Foot 5 0
No details of these cases are given, and we do not therefore
know whether any further operative interference was necessary.
In his paper on compound fractures,^ Volkmann adds the
fact that 21 compound fractures passing into joints were
treated without a death. With regard to these last 21 cases,
we have some further particulars. In 2 instances resection
was at once performed ; in 5 resection was performed
secondarily ; in 3 amputation was performed secondarily ; in
10 there was perfect recovery with freely movable joints ; and
in 1 case there was recovery with anchylosis, but the treatment
was not commenced in this instance till thirteen days after the
injury, and the joint was then already suppurating. In all
these cases there was extensive injury of the bones as well as
wound of the joint. In 3 cases the secondary operation
was performed because the patient was not admitted for some
time after the injury, and the joints were already suppurating ;
in one case the supervention of gangrene rendered it necessary,
and in the other cases the nature of the wound, malposition of
the fragments or suppuration of the joint, required it. Of
course in considering cases of luounds of joints it must always
be remembered, that one can never be certain that all the
causes of putrefaction already present have been destroyed, and
therefore, the probable result is very different from, i.e. much
more uncertain than, that where the surgeon makes the wounds
himself, and where, therefore, he has merely to exclude these
causes. This is well illustrated in the case of compound
fractures.
Max Schede, in his work on amputations, states that he has
treated 15 cases of compound fracture in which joints were
opened. Of these 10 were treated conservatively and healed,
in 9 instances (5 of elbow, 2 of hand, and 2 of foot) with
movable joints, in 1 with anchylosis, where the case was not
admitted for some time, and where there was extensive com-
' ' Diu Behandlung der complicirten Fracturen,' Yolhmaiiiis Sanimlung,
Nos. 117-118.
RESULTS OF VOLKMANN AND SCHEDE. 445
minution of the tibia, numerous portions of which necrosed.
In 2 cases amputation was necessary on account of gangrene ;
in 1 case, which was not admitted till ten days after the
injury, secondary amputation was performed; in 1 case of elbow
injury a partial secondary resection was necessary, and in 1
case death occurred from trismus, the patient not having been
admitted till the thirteenth day after the injury, when the
joint was already suppurating.
Taken together with Volkmann's 54 cases we have 69 cases
with 1 death. With Mr. Lister's 40 cases we have a total of
109 cases of injuries to or operations on healthy joints with 1
death, a death which ought not to be reckoned at all, for the
patient was not treated aseptically from the beginning.
Both Volkmann and Schede mix up the cases in which
treatment was commenced at once with those in which the
patient was not admitted for some days after the injm-y, and
where the joint was already suppurating. If we separate
these cases from the 36 instances of compound fractures with
wounds of joints, of which we have details, we find that 28
came under treatment within forty-eight hours after the
occurrence of the accident, and of these 19 recovered with
movable joints ; in 2 cases primary and in 4 cases secondary
resection was necessary, and in 3 secondary amputation was
performed (twice for gangrene). On the other hand, of the
8 cases which did not come under treatment till forty-eight
hours or more had elapsed, none recovered with movable
joints, 2 recovered with stift' joints, 4 required secondary re-
section, 1 secondary amputation, and 1 died of tetanus. Of
course in judging of the effects of the aseptic or other method
of treatment in preventing the bad effects liable to follow
wounds of joints, the latter class of cases, where treatment is
not commenced for several days, ought to be excluded.
Paul Earth ' published in 1877 the results of the cases of
wounds of the knee-joint which had been treated in the hospital
at Basel since 1873. They were 10 in number. Of these 9
recovered with movable knee-joints and one died of exhaustion.
The latter was a case of compound fracture of the patella along
' Ein Beitrarf zur Behandhmg der pcrforirenden Wunden des Knicgclvniis,
by Paul Barth, Basel, 1877.
440 HESULTS OF ANTISEPTIC SURGERY.
with injury to the right side of the head and fracture of the
lower ends of both radii ; the result of a fall from the first floor
of a house to the street. For four days things seemed to
be going on well, and then the patient began to complain of
pain in the knee. The wound on the forehead began to sup-
purate, and the bone became bare. The patella also necrosed.
An abscess formed in the thigh, and the pus had a foul smell.
The patient sank, exhausted from the prolonged suppurations,
about six months after the injury. In this case purification
had not in all probability been successful in the first instance.
Among these 10 cases we have 6 which were seen soon after
the injury : the other 4 having come under treatment several
days later when suppuration was commencing, or had already
begun. The success in purifying the wounds in these 4 cases is
remarkable ; they all recovered with movable joints. In puri-
fying them, the wound was swabbed out with chloride of zinc,
and then irrigated with strong carbolic lotion, several counter-
openings being also made. The successful disinfection in these
cases was a piece of luck, for one can by no means reckon on
anything like such a result.
Saxtorph of Copenhagen has published the results of his
aseptic practice in removing foreign bodies from joints by free
incision.' He has had 12 cases, 11 being cured and one end-
ing fatally. In this case the patient took off the antiseptic
dressing, suppuration ensued, and the patient died.
Piechaud ^ has collected a number of cases of incisions into
joints. He gives 4 cases of hydrarthrosis of the knee-joint
which were treated by free incisions and aseptic drainage.
They were operated on by Panas, Poinsot, Saxtorph and Lind-
paintner. In 3 of the cases there was perfect cure with
free movement of the joint. In the fourth case, in a strumous
subject, there was some fear that synovial disease was going to
develop, and therefore the patient was discharged wearing a
silicate apparatus with which he could walk about without pain.
Piechaud mentions 3 cases of dislocation of the thumb
where, in order to reduce the dislocation, free incisions were
' Clinique Chirurgicale.
* De la potiction et de Vincision dans les maladies articidaires. Par le Dr.
T. Piechaud, Paris, 1880.
NUSSBAUM: ALBERT: HUETER : LETIEVANT. 447
made into the joint. All recovered with retention of the
normal movements. In a fourth case, the finger, which was
otherwise much injured, became inflamed, and amputation was
performed on the following day. Piechaud also states, that in
the course of the year he had seen in M. Labbe's clinique at
the Lariboisiere several similar cases where wounds of the
phalangeal joints healed by first intention when treated
aseptically.
Professor Nussbaum,' states in his work on aseptic treatment,
that * this method opens up a new field to surgeons. By the
aid of these precautions, joints and the cavities of the body may
be opened without danger.' This is his experience in an un-
healthy hospital.
Professor Albert ^ of Innsbruck says ; ' Die operative ErofF-
nung seroser und synovialer Hohlraumen die bei oflfener Wund-
behandlung regelmassig zur Eiterung fiihrt, fiihrt unter Lister
nicht zur Eiterung. Man kann Hydrocelen, Cxelenke, Schleim-
beutel ohne Gefahr eroffnen.'
Professor Hueter of Grreifswald says ; ' it is with reason that
I said in 1870 that puncture of joints ought to he considered
as a dangerous operation ; it is with as much reason that I now
affirm (1876) that one can practice this operation without
danger. I based my first opinion on the septic accidents con-
secutive to the inflammation.'
M. Letievant of Lyons also says : ^ ' Des tentatives operatoires
nouvelles, tres-graves, devant lesquelles on pouvait hesiter, ont
pu etre mises en application, et si je n'avais eu la securite que
me donnent mes statisques et une pratique deja longue du
pansement listerien, je n'aurais jamais ose ouvrir largement des
grandes articulations, les luxer pour les nettoyer, remettre les
OS en place, drainer et conduire la plaie a guerison.'
Kraske gives details of all the gunshot injuries of joints
treated at Halle aseptically.'* They were 4 in number, and, in
all the cases, the knee was the joint involved. In one case
the movement was perfect, healing having taken place without
' Le pansement antiscptique, 1880,
^ Lehrbuch der CJiirurgie, Wien, 1877.
' Note sur le Panscjiirnt antiKcptiquf Listerien. Lyon, 1880.
* Ji?.ngenbeck's Arr/rir, vol. xxiv.
448 RESULTS OF ANTISEPTIC SURGERY.
the occurrence of suppuration. In a second it was not abso-
lutely perfect, but it was almost right, and was improving ; na
suppuration. In a third the movements were good as far as
a right angle, when the patient left the hospital. In the
fourth case the patella was very much broken up by the bullet
and portions of the bone afterwards exfoliated. The wound had
quite healed in two months. When the patient was discharged
about two and a half months after the accident, the patella
was freely movable and the joint could be moved by the sur-
geon to an angle of 150°. The patient did not return to have
the passive motion kept up, and when seen a year after the
accident, the joint was anchylosed.
I have already alluded to the remarkable results obtained
by Dr. Carl Eeyher ^ during the recent Kusso-Turkish war, and
I must now mention in detail these results in cases where
joints were injured.
Reyher divides the cases treated into * Primary antiseptic
cases,' ' Secondary antiseptic cases,' and ' Non-antiseptic cases.'
By ' Primary antiseptic ' cases he means those which were
treated aseptically from the very first, and which had not been
examined beforehand with dirty fingers or instruments, or
treated in any way. In these cases Reyher either washed out the
wound with an antiseptic solution, removed any foreign bodies
present, drained and treated aseptically, or he did not wash
out the wound at all, but simply contented himself with purify-
ing the exterior and applying an antiseptic dressing. In the
latter cases he trusted to Esmarch's idea that the bullet would
not carry dust into the interior of the wound. The former
practice was adopted where the wound was gaping, and where
there was a suspicion that portions of clothing, &c. had been
carried in with the bullet ; the latter practice, where the edges
of the skin were lying together, and where it was thought that
the bullet had not carried any extraneous matters with it. By
* Secondary antiseptic ' cases he means those which had been
examined or treated in some way opposed to aseptic principles
before coming into his hands. In a few cases suppuration had
already commenced. He tried to purify these wounds by washing
them out with carbolic lotion, but the attempt was seldom
' Volkmann's ,S:r/ww/«/(./7, Nos. H2-14:?, 1878.
GUNSHOT WOUNDS OF JOINTS. 449
successful. They are, therefore, as I have ah'eady pointed out,
cases treated with antiseptics, not aseptically. The ' Non-
antiseptic cases ' were treated either with dry dressing, or with
some watery or oil}' application containing an antiseptic.
Eeyher demonstrates completely that all the cases which
he mentions were perfectly comparable injuries, and that the
results must therefore be due to the different ways in which
the patients were treated. Every case, with the exception of
very severe wounds caused by shell, was treated at the be-
ginning conservatively.
Forty-six cases were treated by 'primary antiseptics,' and
of these 6, or 13 per cent., died. With regard to these 46
cases, however, primary resection was performed in 19, and of
these 2 died, leaving 27 cases treated conservatively with 4
deaths, or a mortality of 14*8 per cent. The following wer3
the joints which were injured : —
Shoulder
Tutal
1
Uealcil
1
Died
0
Pcrcentacre
mortality
0
Elbow .
2
2
0
—
Jlip
1
0
1
100 I), c
Knee
. 18
15
8
16-6 „
Foot
5
0
0
Total . 21 28 4 11 8 ..
Eighteen of these cases were treated without washing out
the wound ; in 9 the wound was washed out and drained. In
none of the 27 was resection or amputation necessary.
The causes of death in the 4 fatal cases were as follows : —
In the injury of the hip-joint acute infl:uiiniation and septic
suppuration occurred : here it was found that the bullet had
carried in a portion of the clothing. One case of knee-joint
injury died fr(jm fatty embolism within twenty-four hours. One
knee-joint case died on the fifth day from htcmorrhage from
the divided popliteal artery and vein. The fourth case had
not died when the rei)ort was issued, but a fatal result was
considered certain from hectic fever and diffuse sup])uration ;
I have therefore included it among the fatal cases.
Seventy-eight cases were treated by 'secondary antiseptics,'
and of these 48, or 61'5 per cent., died. Of the remaining 30
cases, only 8 ultimately retained their limbs, secondary resec-
G o
450
RESULTS OF ANTISEPTIC SURGERY.
tion being necessary in 15 cases, and secondary amputation
Total
Lived
Died
Shoulder- joint
7
4
3
Elbow .
. 11
8
3
Hand .
5
4
1
Hip .
4
0
4
Knee .
. 40
6
34
Ankle .
6
4
2
Tarsus .
5
4
1
Total
78
30
48
Percentage
mortality
42-8 p. c.
27-2
20
100 „
85
33-3 „
20
61-5 „
The causes of death were in 17 cases pyemia ; in 16, septic
inflammations ; in 4, very acute suppuration of the joint ; in
9, hectic ; in 1, carbolic acid poisoning; and in 1 there was
jaundice.
Contrasted with these two sets of cases, there were 62 where
no antiseptic precautions were taken. Of these 39, or 62*9 per
cent., had died when the first report was issued, but in the
Appendix we are told that 9 more had died, the mortality being
thus raised to 77-4 per cent. The causes of death in the 39
cases were, in 23, from pysemia ; in 6, from septic inflamma-
tions ; in 6, from hectic ; and in 1 the cause was unknown.
The joints involved were (first report) : —
Total
Healed
Shoulder .
7
0
Elbow
11
0
Wrist
G
1
Hip .
4
0
Knee
23
1
Ankle
11
1
Total .
62
3
Under
treatment
Died
Percentage
mortalitj
4
3
42-8 p.
5
6
54-5 „
3
2
33-3 „
1
3
75
4
18
78-2 „
3
7
63fi „
20
39
02-!)
The amended table a montli or two later would probably
be
Total
Healed
Under
treatment
Died
Percentafje
mortality
Shoulder .
7
0
3
4
57-1 p. c.
Elbow
11
0
5
6
54-5 „
Wrist
(;
1
3
2
33-3 „
Hip .
4
0
0
4
100
Knee
23
1
()
22
l)o-6 „
Ankle
11
]
1
!)
81-7 „
Total .
«2
3
12
47
7.V8 ..
GUNSHOT WOUNDS OF JOINTS.
4ol
One additional case died, but I do not know what joint was
injured. The number of limbs treated ultimately conserva-
tively is not mentioned.
A similar result is obtained if similar injuries are compared.
Thus take the wounds of the knee-joint ; and first the cases in
which the bullet became embedded in the bones and in which
conservative treatment was tried.
Treated conserva-
tively to eiirl
Intermediate
amputation
Secondary
amputation
2
>
8
s
o
H
>
o
S
>
o
o
o
ri
S
4
5
o
5
5
"3
o
H
4
15
9
t'a
- o
9H-3
100
Primary antiseptic .
Secondary antiseptic
Non-antiseptic .
4
0
0
0
8
4
4
8
4
0
2
2
1
0
These facts are surely striking enough. Out of 28 cases
of wound of the knee-joint where the bullet became embedded
in the bones only 5 lived, and of these four were treated asep-
tically and retained their limbs. One case recovered which was
treated with ' secondary antiseptics,' but only after secondary
amputation.
The results are equally striking if we take all the cases of
wound of the knee-joint.
Primary ~|^
antiseptic /
Secondary "\
antiseptic /
Non-anti- i
septic J
Treated
conserva-
tively to
the end
Secondary
resection
Interme-
diate ampu-
tation
Secondary
amputation
Total
Recovered
6
(5
3
18
6»
o
I
s
1
6
'A
9
S
7
d
12
13
s
6
'A
%
5
so k?
a «
S o
lfi-6
sr,-
78-2
-23
c «
■ s
15
'S tn
18
19
9
9
11
18
40
23
3
31
18
1
* II.-ul did ;i( time of report.
(The last line must be amended, for ultimately only 1 of
(1 a 2
452 RESULTS OF ANTISEPTIC SURGERY.
these 23 non-antiseptic cases lived. Hence the percentage
mortality was 95 '6. )
Thus, of 18 aseptic cases 15 recovered, all with movable
joints. The causes of death in the 3 aseptic cases are given
on p. 449.
Of 63 cases treated otherwise, 7 recovered (5 after amputation,
1 with a stiff knee, and in 1,1 think, the knee was movable).
These results are surely convincing. Keyher truly remarks,
' Das scheint mir eben das Bemerkenswerthe zu sein ! Nicht
dass Knieschiisse conservativ heilten, sondern dass von 18
Knieschiissen welche mir ohne Auswahl auf dem Verbandplatz
zugingen und welche an Schwere der Verletzung den andern
nicht nachstehen, ein so grosser Procentsatz, uamlich 83*3 pro
cent, mit Erhaltung und Beweglichkeit des Gelenkes geheilt
ist.'
Bergmann ^ also got some remarkable results by a smihir
method of treatment during the same war. When the wound
was valvular he did not wash it out at all, but simply purified
the exterior and applied an aseptic dressing. ' After the
storming of Telisch and Gorni-Dubnik 15 cases of compound
fracture of the knee-joint came under treatment, mere injury
of the capsule being excluded from the list. Of these 14 re-
covered, 2 after amputation, and 1 died, also after amputation.'
(MacCormac.)
In comparing these results from gunshot injuries with those
obtained by other surgeons, INIacCormac says: ' Hennen, l^arrey,
and Guthrie all agree that gunshot wounds of the knee-joint
demand amputation, as the result is otherwise fatal. Guthrie
states in his book that he cannot recollect a case of recovery
after gunshot fracture of the articular ends of the bones.
Ijongmorfe tells us that in the Crimea not a single man wounded
in the knee-joint recovered without amputation.' Such state-
ments at once do away with any objection which might be
made to Reyher's cases, to the effect that 18 is a vei-y small
number of cases; for among these there were no less than 15
recoveries with movable joints, a result not obtained at all
according to Longmore throughout the Crimean war, and not
' Ueber die BclmncUung der Schnsswuiidcu dcs KnictjcJciiks in Krirrjv.
Stuttgart, 1878.
GUNSHOT WOUNDS OF JOINTS. 458
obtained in the 63 other cases mentioned by Eeyher. Indeed,
if we were to work out Reyher's tables, we should find that of
600 cases of gunshot wound of the knee-joint treated with
antiseptics, but not aseptically, only 15 would retain unmuti-
lated limbs, and the joints would be stiff. On the other hand,
we only require to take 18 cases and treat them aseptically in
order, not only to retain 15 limbs entire, but also to retain
movement in the joints.
The proper proportions would perhaps be got by comparing
Reyher's aseptic results with those obtained during the Franco-
Prussian war, as published by Heintzel.' These cases were
treated in a variety of ways; by antiseptics, aseptically, by
the water-bath or irrigation, by the open method, &c. Thus
the results are by no means so unfavourable as during the
Crimean and other wars. The sanitary arrangements were also
better. In fact the treatment was much more antiseptic than
formerly. Heintzel gives details of 529 cases of gunshot
wounds of the knee-joint which were treated at the first con-
servatively. In 288 instances amputation was afterwards
necessary ; of these 225, or 78*2 per cent., died ; of the 241 in
which conservative treatment was carried out to the end, 109,
or 45'2 per cent., died. Thus, of 529 gunshot wounds of the
knee-joint treated in a variety of ways, generally more or less
antiseptically, only 132 or 24*9 per cent, recovered. Compare
with this result Eeyher's 83-3 per cent, of recoveries where
the aseptic principle is thoroughly and logically carried out.
I can find no statistics of the results obtained in similar
injuries or operations by other methods of antiseptic treatment.
We have seen in Eeyher's paper the result of treatment by
antiseptics.
Treatment by irrigation, unless a strong antiseptic lotion is
employed, is hardly suitable for these injuries, for there are so
many opportunities for retention and fermentation of discharge
in the interior of a joint. Treatment by water-bath is no
doubt sometimes good, but only as kee-phig dcwn the inflam-
mation, not as preventing the suppuration. The only method
which prevents inflammation and suppuration is the aseptic
' Deutsche militairarzlliche ZeilKchrift, 1S75.
454 RESULTS OF ANTISEPTIC SURGERY.
method, whether it be carried out by operating subcutane-
ously, or by making a crust, or by the use of antiseptics in the
manntu- recommended by Mr. Lister. The latter is, I believe,
the only method by which a wound in a joint may be kept
widely open for some days without the occurrence of inflamma-
tion or suppuration. In order, however, to obtain this result, it is
necessary to observe the minutest precautions- before detailed,
and to act in the very strictest manner in accordance with the
particulate theory of fermentation. It is the omission of this
care which leads to the failures which are recorded as failures
of the aseptic method, but which are really failures on the part
of the surgeon who attempted to carry it out. Surgeons are
too apt to regard the omission, of details, such as the purifi-
cation of hands or instruments, as 'trifling oversights,' ^ and
it is by so doing that they fail to obtain the results they are
led to expect, and that we have such an amount of contradictory
evidence before us.
That no precaution is too minute to be attended to, is well
illustrated by ]Mr. Lister's case of removal of loose cartilage
from the knee-joint (No. 22, p. 434), which was referred to by
him at the meeting of the British Medical Association at Cam-
bridge in 1880. The case was one of loose cartilage in the
knee-joint of a strong healthy man which was removed with
aseptic precautions by Mr. Lister. The operation was per-
formed on April 12, 1880, and there was no difficulty in its
performance. After the cartilage had been removed, a drainage-
tube was inserted into the joint, and a small dressing was
applied. The same evening the discharge was so profuse that
the dressing had to be changed. The discharge had no smell,
and I may say that throughout the case it was entirel}' free
from odour.
On April 13, twenty-four hours after the oj)eration, a speci-
men of the discharge was taken from the drainage-tube, and
after staining with methyl violet, it was found to be full of
organisms. These organisms were very small, and on careful
examination they were found to be of a distinctly oval form
and arranged in pairs. In some parts it was very difficult to
' See Mr. Holmes's report of a case in which he operated for ununited
fracture of the patella in the St. George's Hospital Iteports for 1880.
NECESSITY FOR THE MINUTEST PRECAUTIONS. 455
say whether they were round or oval (see Plate V, Fig. 36).
There was none of the characteristic grouping of micrococci, no
threes in triangles and no pairs side by side. This was seen
not to be due to their being all in pairs, for chains of several
individuals were found, but nowhere the micrococcal grouping.
Again, in a specimen of this pus kept moist on a slide for
twenty-four hours, very long chains were found, but no masses
or typical micrococcal formation. Hence, from the microscopi-
cal examination alone, I concluded that these organisms were
not ordinary micrococci, and other evidence will be mentioned
immediately which supports this view. They were probably
bacteria or micrococci of a peculiar kind not causing -putrefac-
tive fermentation, but the products of whose growth were very
irritating, for that is the only way of accounting for the profuse
discharge from the interior of the joint.
Redness occurred around the wound, and spread a little
distance up the thigh. In the meantime, the patient's tem-
perature became high and the constitutional disturbance was
considerable.
On April 15, there was still profuse discharge, now distmctly
purulent, but no smell ; and in the stained specimens of the dis-
charge taken on this day, the organisms presented exactly the
same characters as on the 13th.
On the 16th, a quantity of pus was pressed out of the joint ;
an incision was also made into the inflamed part in the thigh
and a quantity of sero-purulent matter escaped. A drainage-
tube was inserted into this abscess.
On April 18, the state of matters continued the same. In
the stained specimens of this day's discharge, numerous organ-
isms were seen, many of which were distinctly oval in form,
but a large number were round (Fig. 37, Plate V). Two flasks
of cucumber infusion were inoculated from the wound on this
day, but no developfnent occm-red in them.
In spite of the incision into the thigh, the suppurative in-
flammation spread, and a large abscess cavity was soon formed.
As the drainage of the joint was not good, an opening was made
on the outer side and a drainage-tube inserted. There was
distinct improvement after this. The acuteness of the process
soon began to abate.
45G RESULTS OF ANTISEPTIC SURGERY.
On April 22, the discharge from the drainage-tube of the
abscess was found to contain organisms of the same characters,
though fewer in number than formerly (Fig. 38, Plate V).
On this day a flask containing iinieat infusion, and one con-
taining cucumber infusion, were inoculated with discharge from
this abscess, but no development occurred in either.
The state of matters continued with but slight improvement,
and organisms were always present, though not so numerous as
at first. On April 27, a flask containing alkalised cucumher
infusion and a fresh egg were each inoculated with discharge
from the inner side of the knee, but no development occuiTed
in either. And on April 30, two eggs were inoculated with
discharge from the outer side of the knee without any result.
On ]May 9, discharge taken from the abscess cavity showed
the presence of organisms few in number but possessing the
same characters as formerly. A flask of pure vitreous humiour
of a sheep and a flask of ordinary cucumber infusion were
inoculated from the abscess cavity. Nothing developed in
either fluid.
With regard to the ultimate result in this case, I may say
that improvement now began, and healing was complete and
the limb restored to a sound state, during the month of Sep-
tember, though there had been very little indeed to heal for a
month or six weeks previously. There was a considerable de-
gree of fibrous anchylosis. The patella was quite movable
laterally, and there was a little movement between the tibia
and femur, Avhen the patient was discharged.
Now, first as to the nature of these organisms. They were
certainly not ordinary micrococci, for they had not the same
appearance or mode of growth, and also they did not grow in
any of the various materials into which they were introduced.
The micrococci of which I have spoken in a former part of this
work, and, indeed, any which I have as yet come across, would
have grown with great readiness in several of these fluids.
This was evidently a peculiar form of organism (probably bac-
terium), not causing putrefaction, but nevertheless, locally of a
very noxious character. Had it not been for the microscopical
examination, one might have concluded that no organisms were
2s^ECESSITY FOR THE MINUTEST PRECAUTIONS. 457
present and been puzzled to explain the phenomena on anti-
septic principles, on the supposition that organisms were absent.
How did they get in ? If the aseptic method is sufficient,
as I have asserted it is, how were these organisms admitted ?
As we have already seen, the only organisms which usually get
into aseptic wounds are micrococci. Here the organisms
differed in many respects from those ordinarily found, and the
ordinary forms of micrococci were absent. Hence they probably
did not get in in the same way as micrococci usually do, that is,
as I have previously shown, through the dressing ; for the ordi-
nary forms of micrococci are the first to enter, and would, I
think, have been found had that been the explanation. Not
only so, but these organisms must have got in at the time of,
or very soon after, the operation, in order to be present in such
numbers on the next day and also to account for the imusual
amount of discharge on the evening of the operation.
And they did not get in through the circulation, for there
also micrococci are found as a rule first, and here there was no
disturbance of the general health to accoimt for their existence.
Whence, then, did they come ? Were they perhaps spon-
taneously generated ? Truly an awkward sort of spontaneous
generation for the patient ! But why should the mere removal
of a loose cartilage from a joint lead to the spontaneous develop-
ment of organisms in it ? There was no formation of a
vacuum in the joint. There was no change in the physical
forces. There was no introduction of cheese a la Bastian into
the wound. If organisms were to develop spontaneously in the
joint, why did they not do so the day before the operation
rather than immediately after it ? I need not pm-sue the
many arguments against this view; for we have previously
seen that in exact proportion to the care in making experi-
ments do the facts supposed to favour spontaneous generation
disappear.
Two explanations therefore remain. Either we had here to
deal with some form of resisting spore, or with one which
escaped the action of the carbolic acid, or there was some loop-
hole in the method. The former supposition I am inclined to
reject, for various reasons which I cannot discuss here : we
458 RESULTS OF ANTISEPTIC SURGERY.
have certainly had no previous experience of bacteria resisting
the means employed.
There was, however, I believe, a very distinct loop-hole in
the method as practised at that time. This is alluded to at
length on p. 79. I had long thought that the drainage-tube
might carry into a wound dust-laden air in its interior, if the
air which entered the tube on removing it from the carbolic
lotion were not purified by carbolic spray. This is the explana-
tion I offer here, viz. that the air carried into the wound by the
drainage-tube was not pure air, but contained a particle or par-
ticles which gave rise to this particular form of organism. On
mentioning this to Mr. Lister, he at once saw the force of the
argument, and since that time he takes precautions to prevent
the recurrence of a similar accident.
It is just possible that the fault lay in the fact that a very
small dressing was applied at the time of the operation, and
that they got in through the dressing. But then they must
have got in during or very shortly after the operation, in order
to produce the rapid effect which followed. And also, as I have
just stated, the ordinary forms of micrococci would probably
have been found in that case.
The only other explanation would be, that there was some
error in the manipulations. But though, no doubt, faulty
manipulation is almost the constant cause of failure in those
commencing the practice of this method and in those who
have practised it, when the operation is difficult and requires
much thought, yet here there was a simple operation, the im-
portance of the aseptic precautions were fully present to the
mind, and I do not think that, especially in the case of Mr.
Lister and his assistants, this explanation is in this instance
the most probable one. Whichever explanation, however, be
correct, the case is of great importance, as confirming the views
expressed before, as illustrating the necessity of excluding
organisms of all kinds, and as showing the results which may
follow the admission of bacteria to wounds. It is also of in-
terest, because it shows that forms of bacteria may be present
without the production of smell, and thus, because a discharge
is ' stueet, ' it is not necessarily ' aseptic' The difficulty which
was experienced in finding the organisms before the pus was
VALVULAR METHOD OF OPENING JOINTS. 459
stained also warns us how careful we must be in deciding
whether organisms are present or absent from wounds. Cases
have been published where disastrous consequences have fol-
lowed incisions into joints, but where the surgeon has asserted
that the discharge was sweet and free from organisms. Ac-
cording to recent investigations, however (p. 253), we know
that the pus of acute abscesses and from acute suppurations
always contains organisms, generally micrococci ; and therefore,
in the published cases in which the assertion to which I have
alluded has been made, it is clear that the presence of organ-
isms has been overlooked ; for if no other form was present,
micrococci were sure to be there.
Various facts are known as to the removal of foreig'n bodies
from joints without aseptic precautions. A number of these
have been referred to in the historical part, and I will here
content myself with quoting some figures from a paper pub-
lished by M. Larrey in 1861. As we have seen in considering
the History of Antiseptic Surgery, the valvular method intro-
duced a considerable amount of security into these operations.
Larrey groups the results of the direct and of the oblique, or
valvular incision together, but the details are very meagre.
He mentions 132 cases, of which 30 died ; 7 were unsuccessful
or uncertain in result; in 10 he mentions the occmrence of
anchylosis ; in 2 of hydrarthrosis ; and in 9 of grave accidents
not further specified. There are thus left T-i cases which were
possibly cured with movable joints, but he expressly states
that all the cases of healing in which accidents occurred are
not noted, so that the number of cures is really less. Thus,
only about one half of the cases recovered without the occur-
rence of some serious complication, yet these results, though
apparently so bad, are much more favourable than those which
had been obtained by several other surgeons, Larrey contrasts
with these cases the results of the operation in which a bed is
made outside the joint to receive the cartilage. Of these he
mentions 38 cases with 19 cures, 15 failures to extract the
cartilage, and 5 deaths.
Larrey's statistics express very well the opinions of the
majority of surgeons on the dangers of extracting foreign
bodies from joints, even when the valvular or subcutaneous
400 RESULTS OF ANTISEPTIC SURGERY.
method is employed. If we search the sm-gical text-books we
find that there is throughout a fear of such operations or in-
jm'ies. Thus, Mr. Spence, in his ' Lectures on Surgery,' says,'
* There is no class of operations that I have a greater dread of
than the apparently simple one of removing a loose cartilage.'
I have no statistics of septic cases, comparable to the asep-
tic ones, in which wounds of joints have been kept open for
some days ; but, as will be seen in the history of this subject,
experieuce has up till recently led surgeons to the conclusion
that the safety of the limb and of the patient depends on rapid
healing of the wound. And yet, as all the facts quoted show,
these operations, when aseptically performed, are really devoid
of danger. Sir James Paget says : ^ ' I cannot doubt that
operations of this kind ' (referring to incisions of joints with
closure of the wound), ' which, in the earlier years of my work,
were done with great risk, or, with a wise fear of the risk, were
left undone, may now, with antiseptic help, be done with an
almost complete safety.'
' See leading article in British Medical Journal^ April 1880.
* MacCorraac's A ntiseptie Surgery.
RESULTS IN COMPOUND FRACTURES. 401
CHAPTER XIX.
RESULTS OF ANTISEPTIC SUEGEKY (cO) it I lilted).
CompDUiid fractures. Differences between those produced accidenlallj' and
those caused by the surgeon : treatment and after-progress of each class.
Tables of accidental compound fractures treated by Mr. Lister : thigh ; leg ;
humerus; forearm ; skull ; summary of results. Tables of compound frac-
tures produced intentionally by Mr. Lister ; femur ; leg ; clavicle ; hume-
rus; forearm ; lower jam. General summary of Mr. Lister's results. Mr.
Spence's results. Other operations on bones by Mr. Lister. MacEwen's
osteotomies : Volkmann : Max Schede : Bardenheuer : MacCormac. Com-
bined aseptic results. Results by other methods : Volkmann and Fraeuc-
kel : Holmes : St. Thomas's Hospital. Reyhers results in war. Open
method : Kronlein. Septic methods.
I NOW pass on to a second class of cases which are often fol-
lowed by most serious consequences : I refer to compound frac-
tures occm-ring accidentally or made by the surgeon.
Compound fractures produced accidentally and those made
by the sm'geon differ from each other in various important par-
ticulars. In the first class dust is as a rule introduced into
the wound before the surgeon sees the case, and, therefore, the
problem is to destroy the energy of this dust. VV^hether such
an attem])t is successful or not, must of coiu'se always be a
matter of doubt ; and hence the results are uncertain. Then,
also, the violence is often very severe and complicated with
other injuries or with shock, and in this way life may lie lost
from causes which could not be avoided by any method of
wound treatment. On the other hand, in the second class of
cases the surgeon has only the ordinary aseptic problem before
him, and if he is justified in other cases in looking with cer-
tainty for good results, he ought to be equally justified here.
He is also independent of the other injuries and shock which
so often comi)licate accidental coni])oun(l fractures, and, there-
fore, the mortality ought also to be less. If we remember
462 RESULTS OF ANTISEPTIC SURGERY.
these differences, we shall be able to form a just estimate of the
value of the results.
The aseptic course in these cases corresponds to that de-
scribed in Chapter XVIII. ; and I need only indicate one or two
points in the treatment and after-progress of the injury.
The treatment of compound fractures the result of accident
has been already described at pp. 113 and 114. It consists in
washing out the wounds thoroughly with a strong antiseptic
lotion, generally the 1-20 watery solution of carbolic acid or the
1-5 mixture of carbolic acid and methylated spirit. This is done
by injecting the lotion through a catheter attached to a syringe
filled with the solution, the orifice of the wound being left
freely open. In this way, by moving the point of the syringe
in various directions, the lotion is introduced with certainty
into all the recesses of the wound, while by leaving the orifice
of the wound freely open there is no risk of forcing the fluid
into the cellular tissue. It is well to clear out all the clots of
blood. The skin in the neighbourhood is also thoroughly
washed with 1-20 carbolic lotion, the whole being done in a
spray of carbolic acid. The wound is left freely open, and in
most cases a drainage-tube is passed into the deeper parts and
kept in for a few days. In some instances, if there is much
tendency to displacement, the ends of the fragments may be
tied together with strong silver wire. A large gauze dressing,
enveloping the limb, is then applied, and outside it a suitable
splint. This dressing is changed on the following day, and
afterwards according as it is necessary. After a few days, in
compound fractures of the lower extremity, when the discharge
has become small in amount, some arrangement like that de-
scribed at p. 107 may be employed.
The after-progress of these cases depends on whether the
causes of putrefaction were destroyed or not by washing out
the wound. If they were not, then the case becomes one
treated with antiseptics, but not aseptically. If the causes of
putrefaction were eradicated, the wound follows an ' aseptic
course' (p. 421). In cases of compound fracture, more especi-
ally from direct violence, the soft parts are often much con-
tused and lacerated, and the bones are sometimes comminuted
and much injured. The ordinary result in such cases, when
'ASEPTIC COURSE OF COMPOUND FRACTURES. 463
aseptic treatment is not employed, is, that sloughing of the con-
tused and lacerated tissues occurs to a greater or less extent, and
very generally portions of the broken fragments of the bone be-
come necrosed. This process is accompanied with a considerable
amount of suppuration. If, however, the wound is rendered
aseptic, and if the irritation of the antiseptic is excluded, this
sloughing and suppuration does not occur. The wound be-
comes filled with blood-clot ; the interstices between the frag-
ments of lacerated tissue also become filled up; the whole
remains unaltered for many days, merely assuming a greyish
appearance on the surface, but after some days, on scratching
this clot, it bleeds, showing that it has become vascularised,
and on detaching the superficial layer the greater part, or
XVTT
Fig. 78.— Temperatcke Chart from a Case of CoixrouxD Fracture,
IN WHICH THE ATTEMPT TO ERADICATE THE CAUSES OF FERMENTA-
TION WAS UNSUCCESSFUL, AND WHICH THEREFORE BECAME A SEPTIC
CASE (Case 26, p. 472).
indeed the whole of the wound, will be found to have become
covered with epithelium. (This process will be more minutely
discussed hereafter.) There is no suppuration at all from the
wound, and no separation either of dead skin or tissue, or of
dead bone. If, however, no protective be used, or the wound
be deluged with strong carbolic acid, the superficial layer of
the clot becomes irritated, and when vascularised, granulates,
and suppuration occurs from its surface ; at the same time, the
portions of dead tissue being impregnated with carbolic acid,
become irritating, cause granulation and su[)puration where
they are in contact with the living parts, and are thus separated
as sloughs. The sloughing in this instance, however, is not as
a rule nearly so extensi\e as in the case of a septic wound.
464
RESULTS OF ANTISErTIC SURGERY.
The constitutional condition also depends in the main on the
success or failiu-e of the attempt to render the wound aseptic.
If the attempt fails, the temperature is generally high, as in
other septic cases (see fig. 78) ; if, on the other hand, it is
successful, the temperature generally remains normal or nearly
so, though it may be high for a few hours after the injury
(see fig. 79). (I shall not go into this matter further at pre-
sent, as I intend to discuss it more fully in a future chapter.)
The general well-being of the patient also closely corresponds
to the septic or aseptic state of the wounds ; if the wound is
septic and the temperature high, the patient generally feels ill,
and has other symptoms of fever ; if, however, the wound is
BBsaiiii
I
mH—8Bai
Fig. 7'J.— Temperature Chart from a Case of Compound Fracture
Which followed an Aseptic Course (Case 23, p. 472).
rendered aseptic the patient feels practically iu a normal state
of health.
In the case of compound fractures made by the surgeon, the
progress of the wound and the constitutional state of the
patient are similar to those described as typical of operations
on joints (p. 421); and I need not repeat what I said there.
In performing these operations a free incision is made down
to the bone with the various aseptic precautions ; the bone is
chiselled or sawn across, or a portion of bone is removed accord-
ing to circumstances ; the bleeding vessels are secured ; a
drainage-tube is introduced down to the bone ; as a rule, no
stitches are inserted ; and the dressing is applied according to the
ordinary rules previously described. In a few hours the wound
is filled with blood-clot, which becomes vascularised and organ-
COMPOUND FRACTURES. 465
ised, and cicatrisation occurs beneath its superficial layer without
previous granulation or suppuration. As a proof of this I may-
refer to the fact mentioned by Dr. MacEwen, that he had
made 835 compound fractures, and that in only 8 of the wounds
was there any pus formation, although none of these injuries
was subcutaneous. After operations conducted in this way the
general state of the patient remains normal.
In considering the results of compound fractures, it is quite
clear that all cases, in whatever way they are treated, whether
by primary or secondary amputation or conservatively, must
be mentioned and grouped together in the first instance.
For the frequency of primary amputation after compound
fracture will depend not only on the great severity of the injury
and destruction of tissue, but also on the dangers to which, in
accordance with the experience of the surgeon in charge, the
patient will be afterwards subjected. If the surgeon feels that
the method of treatment which he has been accustomed to
adopt in these cases is not such as to secure the patient from
the after consequences, he will naturally take into frequent
consideration the question of primary amputation. If, on the
other hand, he has been led to expect that the dangers incident
to these injuries are not likely to occur under the method of
treatment which he adopts, he will perform primary amputation
less frequently. Therefore, in order to judge of the results of
any method of treatment in compound fractures, the number
of primary amputations and the sort of injuries in which they
are performed must be mentioned. With regard to secondary
amputation it must be remembered that these, as well as the
fatal cases, are those in which the attempt to treat conserva-
tively has failed, and therefore it is not sufficient merely to
state the results of cases treated conservatively to the end. In
the following tables I have attempted to indicate, as fairly as
possible, the nature of the injuries and the after-progress of
the cases which have occurred in Mr. Lister's practice since
1872. In some instances the notes have been deficient, but I
have tried to render them complete by tracing out these cases
as far as I could.
II n
466
RESULTS OF ANTISEPTIC SURGERY.
I. Compound Fractures, the
In considering these I have included all Mr. Lister's cases since
1871 : those requiring primary amputation as well as those treated
Comjwund Fractures
Name and Age
Date of Admission
and Discbai-ge ;
with Result.
Injury
A ca^e of extensive, compound fracture of the femur where primary amputation was
performed at the hip-joint. Tue patient died almost immediately. There is no record o!
J. S., 45
George P., 12
^f/., .Iune26, 1874.
Died., June 26, „
Cause of death was
shock.
Ad., Sept. 29, 1871.
Dis., Feb. 14, 1872.
In process of cure.
R. P., 17. .
(Septic case)
Mrs. D., 50
Jd., Nov. 15, 1872.
/>/W,l)cc. 14. „
Cause of death was
bronchitis and car-
diac disease.
.<4rf., Oct. 1.5,1878.
Dis., .lunc 20, 1879.
Result, healed.
Extensive conipmind comminuted fracture of
the femur, and severe laceration of leg
Compound fracture of the femur from a fall.
Direct violence.
Two railway trucks jiassed over his le,n,
causinj; a' simple commmuted fracture ot
both bones of the leg, and a simple commi-
nuted fracture of the thigh. The skin
over the fracture of the femur sloughed,
and the bone protruded on November 22.
Patient was sulfering from cardiac disease.
Compound fracture of tlie femur.
There were thus five compound fractures of the femur, of which
two were amputated primarily, both dying of shock ; and three were
treated conservatively, one of these dying of bronchitis and cardiac
Coiiijioitnd Fractures
William K., 12
A. R., 18.
Ad.. .Tune 17, 1872.
Died, same day.
Cause of death was
shock.
Ad., April 7, 1874.
Din., Sept. 3. 1874.
Result, cured.
Compound fracture of left leg and right thigh.
Skin torn off for a considerable distance.
Patient in a slate of collapse when ad-
mitted.
Leg crushed l>y a beam. Severe compound
comminuted fracture of the leg.
MR. LISTERS COMPOUND FRACTURES.
4(37
Result of Accident.
conservatively or amputated secondarily. I omit the lesser compound
fractures of the hand and foot.
of the Femur (accidental).
Treatment
Remarks
the case in the books, but I know that it occurred.
Primary amputation just below the
trochanters.
Wound injected -with 1-20 carbolic lotion.
Opening enlarged. Drainage-tube in-
serted, and splints applied.
An attempt was made to keep the plough
sweet, liut ]uitrefacti(in liad already
occurred, and therefore the attempt
was unsuccessful.
See No. n, p. 424, and No. 70.
Patient was unconscious when admitted, and never
rallied. He died in about tAvo hours. Cause
ot death was shock.
The bones had firmly united on November 14, and
ihc patient seems to have done well. On
January 19 the sinus had not yet closed, and
Mr. Lister introduced a pair of sinus forceps to
see if there was any loose bone. No precau-
tions were used to' disinfect the air which
entered (no spray or carbolic lotion), and putre-
faction seems to have followed. When the
patient was discharged there was still a piece
of bare bone to be felt, but he was in perfect
health. ^
Abscesses formed about the knee and higher up in
the thigh. The notes are incomplete, Imt the
patientisentered in the hospital books as having
died of bronchitis and cardiac disease, from
which he was suffering previous to admission.
(This was a septic, not an aseptic, case, so that
whatever was the cause of death, it does not
influence the result in aseptic cases.)
Aseptic course. The wound healed, but the bones
did not unite. (See T. Chart II, p. 438.)
disease. This last was, however, a septic case, and therefore all the
cases (two in numlier) of compound fracture of the femur treated
conservatively and aseptically recovered.
of the Le(j {accidental).
Primary ami. utation through the upper Patient never rallied, but died in (wo or three
i of left leg and upper I of right thigii. hours from shock.
Primary junputation. (Modified Carden.)
For some lime Ijir p.i(i(.ni stiO'ered from carbolic
poisoning, but after tlie carbolic dressings were
left off and boracic dressings were substituted
for them, he soon recovered, and the stump
healed slowly.
H H 2
468
RESULTS OF ANTISEPTIC SURGERY.
I. Compound Fkactures, the
No.
10
12
Name and Age
F. D., 22 .
James B., 18
R;H., 25.
George A., 41
George S., 24
(Septic case)
13 James D., 24
Peter M., 22
(Septic case)
15
Anne L., 60
Date of Admission
an<l Discharge ;
with Result
Ad., Dec. 12, 1873.
/>/.s., March 13, 1874.
Result, cured.
Ad., Aug. 3, 1874.
Dis., Sept. 13, „
Result, cured.
^rf., March 17, 1874.
Dis., April 27, „
Result, cured.
Ad., July 1, 1872.
Died, 3n\y 3, ,,
Cause of death was
exhaustion.
^rf., March 15,1872.
Died, May 20, „
Cause of death was
diphtheria.
Ad., Aug. 2, 187
Dis., Sept. 17, ,,
Result, liealcd.
Ad., Sept. 9, 1872.
/-»«., Oct. 31, „
Result, cured.
Ad., Oct. 28, 1872.
Died, on same day.
Cause of death was
shock.
Injury
Railway engine passed over leg, almost sever-
ing the foot, and producing a severe com-
pound comminuted fracture of the leg.
Raihvay engine passed over his ankle, crush-
ing the bones very severely. A consider-
able amount of shock.
Very severe compound fracture of both bnnes
of the leg. Foot drawn through a port-
hole of a vessel by an anchor chain.
Compound comminuted fracture of both
bones of the leu.
Compound comminuted fracture of both
bones of the left leg. Fracture of right
thigh with very severe bruising. Patient
almost moribund.
The wheel of a cab passed over the leg,
causing a compound fracture. Small
wound.
Severe compound comminuted fractnre of
both b(mes of the leg. Leg crushed by a
heavy stone.
Compound comminuted fracture of the leg.
Also fracture of the pelvis. Patient mori-
bund when admitted.
MR. LISTERS COMPOUND FRACTURES.
469
Result of Accident {continued).
Primary amputation through the calf.
Primary amputation through the upper
third of the leg. (Modified circular.)
Primars' amputation just below the knee.
(Modified circular.)
Wound enlarged and injected with 1-20
carbolic lotion. Wound left open.
Wounds washed out with 1-20 carbolic
lotion. (Secondary amputation.)
Wound enlarged and injected with 1-20
carbolic lotion. Wound left open.
Washed out with 1-20 carbolic lotion.
(Secondary amputation.)
Wound injected witli 1-20 carbolic lotion.
Remarks
Haemorrhage occurred on several occasions in
connection with a portion of the anterior flap
which sloughed, but the rest of the wound did
well, and the whole was quite superficial on
February 1, and quite healed when the patient
was diachargeJ.
Aseptic course (i.e. no local or constitutional dis-
turbance). The wound healed by first inten-
tion except where the drainage-tubes were and
at the centre of the flaps, where a little gaping
occurred. The wound was absolutely' healed on
September 18.
The line of incision healed for the most part by
first intention. A slight tendency to gaping at
the centre of the incision was easily overcome
\>y the use of strapping applied aseptically.
Wound was quite healed when the patient was
discharged.
Patient got gradually weaker, and, without any
special symptoms, died in forty hours.
Putrefaction was not avoided, and on March 17,
when this was evident, amputation was per-
formed through the middle of the thigh. This
wound had almost completely healed when, on
May 17, he complained of sore throat. His
temperature went up ; diphtheritic patches ap-
peared on the fauces ; and he died on May 20
from diphtheria. (See T. Chart XVIII.)
Aseptic course. The temperature only once rose
above 100° F., and then it reached 101° F.,
thirty-six hours after the accident. The wound
had quite healed, witliout any suppuration, by
September 7. The bones were not quite firm
when the patient was discharged. He was sent
out with the leg in a case of plaster of Paris.
Putrefaction was not avoided, and as the tem-
perature was going up (it had readied 103"^),
Mr. Lister thought it better to amputate. This
he did through the lower third of the femur on
September 13. The stump followed a perfectly
aseptic course, and liealed by first intention,
except where the drainage tubes were. It had
completely healed on October 18.
Patient died three hours after admission. On
]). m. examination extensive fractures of the
sacrum and pelvis were found.
470
RESULTS OF ANTISEPTIC SURGERY.
I. Compound Fractures, the
Name and Age
William K., 16
J. M., 32 . . .
(Septic case)
IS
J. McA. .
19
20
James B., 56
(Septic case)
22
A. R., 25 . . .
(Septic case)
T. N., 30 .
Jane L., 36
Date of Admission
and Discharge ;
with Result
.4tZ., March 26, 1873.
7>is., July 12, „
Result, cured.
Ad., June 16, 1873.
Dis.. Sept. 15, „
Result, cured.
Ad., Aug. 22, 1873,
Dis., Dec. 18, „
In process of cure.
Ad., Sept. 15, 1873.
Dis., March 12, 1874.
In process of cure.
Ad., Feb. 18, 1875.
D!s., Sept., „
Result, cured.
Ad., April 26, 1875.
Dis., Sept. 20, „
Result, cured.
Ad., Oct. 18, 1875.
Z>is., March 11, 1876.
In process of cure.
Injury-
Compound fracture of both bones of the leg.
A piece of stone fell on his leg. Admitted
tweuty-four hours after the accident.
The wheel of a tramway car passed over li.s
leg, causing a compound comminuted frac-
ture of both biines. Patient admitted im-
mediatelv.
A stone fell on his leg, causing a compound
comminuted fracture of both bones. The
patient was admitted two hours after the
accident.
A van ran over his leg, causing compound
fracture of both bones, two inches above
the ankle-joint. Seen at once.
Leg was run over. Severe compound commi-
nuted fracture of both bones. Admitted
two hours after the accident.
Compound fracture of tibia causid by a
wooden beam falling on his leg. Upper
end of lower fragment protruding. Acci-
dent happened four hours before admission.
Compound fracture of tibia. Leg crushed by
a wooden beam. Lower end of upper frag-
ment protruding. Done four hours before
admission.
II
ME. LISTERS COMPOUNI) FRACTUliES.
471
Result of Accident (contlvued).
Wound injected with 1-5 solution of car-
bolic acid in methylated spirit.
tVounds enlarged. Mdntyre splint
applied.
Wound injected with a solution of cnr-
bolic acid in methylated spirit, 1-5.
Some frapments of hone were remrved.
The wound was washed out with car-
bolic lotion, 1-20.
Wound injected with 1-20 embolic lotion.
Wound injected v ith 1-20 carbolic lotion.
Wourd injf (ted with 1-20 carbolic lotion.
Wound wa*-! ed rut with l-fO cnrliolic
lotion.
Remarks
Putrefaction avoided. A small abscess formed
in the leg and was opened on March 31.
Afterwards the wounds progressed well, and
were sujierfirial on May 16. Boracic dressing
was then applied. ErA'sipelas attacked the
wound on May 2'6, but it had passed off on Maj'
30, and tlie wounds healed rapidly. Tlie bones
were fjuite firm and there were onh' two super-
ficial spots to heal when the patient was dis-
charged.
Putrefaction was not avoided. The wound suppu-
rated freely, and a small piece of bone necrosed.
The temjierature was not regularly taken, but
for twelve davs it was above IHO^ F., ranging
from 100" to l*03-5<-'. The bones had united and
the wounds had almost healed when the patient
was discharged.
Putrefaction was avoided. There was a A-ery
little superficial ' ,'intiseptic suppuration.' There
was no inflammation or formation of abscesses.
When discharged the leg was firm, but there
was still a sinus leading down to bare bone.
The temperature only once rose to 100°, thirty-
six hours after the accident.
Putrefaction was at first avoided, but the pa-
tient, during an attack of delirium tremens,
tore off the dressings, and the wound jnitrcfied.
It was henceforth treated with lint soaked in
carbolic acid and glycerine. When discharged
there was still a sinus leading down to bare
brne, but the bones were quite firm.
Putrefaction was not avoided. Two abscesses
formed, and the wound ard the abscess cavities
supjiuratcd. For six weeks the temperature
varied from 1(0" to 103" V. Other al)scesses
formed, but ultimately the parts began to re-
cover, and healing was coniplete at the end of
September.
Aseptic course. The highest tcni])eralure recorded
■was 99-7°. 'J'lie wound liad healed (exact date
not given), and the bones had united when the
patient was discharged.
Xo constitutional disturbance, but two Fmall
frapments lost tlieir vitality, ai-d were not re-
moved till a few (lays before tlie patient was
discharged. At that time the bones were firm,
and tliere remained only a small superficiHl
sore.
47l>
RESULTS OF ANTISEPTIC SURGERY.
I. Compound Fractures, the
Name and Age
23
■24
25
26
James G., 11
William R., 50 .
Mary V., 55
Andrew F., 38 .
(Septic case)
Cornelius N., 34
28 Maria L., CO
Date of Adniifsion
and Discharge ;
with Rpsuit
Injury
Ad., June 23, 1876.
Z>/s., Nov. 23, „
In process of cure.
Ad., Jan. 26, 1877.
Dis., March 15, 1877.
Besu t, cured.
Ad., Nov. 9, 1877.
Dis., Aug. 14, 1878.
Result, cured.
^IcZ., March 16,1878.
Dis., Dec. 2,
Result, cured.
Ad., May 24, \87i
Dis., Dec. 18, „
Result, cured.
Compound fracture of both bones of the leg.
Admitted immediately after the accident.
Compound fracture of tibia, caused by a kick
from a hor<e. Admitted immediately.
Run over bj' a cart which caused a compound
comminuted fracture of both bones of the
leg.
The wheel of a van passed over his leg, pro-
ducing a very bad compound fracture of
both bones just above the ankle-joint.
Great injury to the soft parts. There was
also a compound C(Jlles' fracture. See
No. 42.
Leg jammed between a stone and the wheel
of a truck, resulting in compound commi-
nuted fracture of both bones of the leg.
Result, cured.
Compound fracture of fibula, etc.
ries of joints. No. 10, p. 424.)
(See inju-
MR. LISTERS COMPOUND FRACTURES.
473
Result of Accident [continued).
Wound injected with 1-20 carbolic lotion.
Wound injected with 1-20 carbolic lotion.
Wound left open as usual.
Wound syringed out with 1-20 carbolic
lotion.
Wound washed out with 1-20 carbolic
lotion. On the followinic day, in order
to get the bones in pnsition, it was
necessary to saw off portions and tie
the fragments together with silver
wire.
Wound enlarged and pieces of bone
removed. Wound washed out with
1-20 carbolic lotion.
Aseptic course. The bone took a long time to
unite, and was not absolutely firm, though
almost so, when the patient was discharged
wearing an immovable apparatus. (See T.
Chart XIX.)
Aseptic course. Beautiful example of organisa-
tion of blood-clot, without suppuration. Heal-
ing complete on February 28. The tibia was
found to be firm on March 6. (See T. Chart
XX.)
Apparently no constitutional disturbance, though
the temperature was above 100^ on several
occasions. A portion of the skin sloughed. No
exfoliation. Put up in plaster of Paris on
January 23, 1878. Taken down on March 14,
but the bones were not then quite firm. One
or two apparatuses were subsequently applied,
and when the patient was at length discharged,
union was complete. (See T. Chart XXI.)
The attempt to eradicate the causes of putrefac-
tion was not successful, and the Avound sup-
purated. The patient had fever. An abscess
formed in the leg. The wounds were quite
healed on June 5. The wire was removed on
July 23. In November the bones were found
to be soundly united. (See T. Chart XXII.)
The greatest difficulty was experienced in keeping
the bones in position, and there was conse-
quently great pain. The temperature was high
for some days, but the pulse was not fast, and
the patient seemed well with this one exception.
For some days the bones became constantly
displaced, but otherwise the wound did well.
It remained asei)tic, though as the result of the
disturbance theie was suppuration, but only a
very little. As the wound got smaller it was
found that the bones could be kept in position
by a screw pressing on the ui)i)cr fragment.
The leg was put up in jilaster of Paris, but on
November 29 the bones were found to be still
ununited. Eigiit to ten minims of tincture of
iodine were therefore injected between the frag-
ments. Some swelling and a small abscess
resulted, and tlie bones united. When seen on
Januarv oO, 187'J, union was complete. (See
T. Chart XXIII.)
Patient did well.
474
RESULTS OF ANTISEPTIC SURGERY.
I. — Compound Fractures, the
No.
29
Name and Age
Date of Admission
and Discharge ; with
Eesult
Injury
F. C, C . . .
(Septic case)
Ad., Dec. 4, 1878.
/J/s., April 20,1879.
Result, cured.
Lei;' run over by a cab. Larj^e wounds on
both ^ides of the leg, that on the outer side
communicating with a fractured fibula.
On the inner side the tibia was bare.
m
Alfred A., G .
Ad., Sept.. 12, 1879.
/>/«., Oct. 19, „
Residt, cured.
Compound fracture of both bones of the leg.
Tibia protruding. Cause not given.
31
Frederic H., 48
^<Z., Nov. 14, 1879.
Dis., -Jan. 5, 1880.
Result, in process of
cure.
Compound fracture of the lower end of the
right fibula and sini|)le fracture of the
middle of the right tibia. Result of a fall.
There were thus under Mr. Lister's care during these years 26
cases of compound fracture of the bones of the leg, of which 4 died.
Three of these deaths occurred within forty-eight hours, and the
other was from diphtheria. None of the deaths was therefore pre-
ventible by any method of after-treatment of the wound.
In 5 of the 26 cases primary amputation was necessary. One of
these cases died of shock.
Twenty-one cases were treated conservatively, and of these 3
died.
Of these 21 cases 2 required secondary amputation, of which 1
died of diphtheria. Of the remaining 1 9 cases 2 died, both from
shock and exhaustion, within forty-eight hours.
.^2 R. J.. 2;?
33
34
35
George G., 60
Henry A., 12
Henry B., 22
Ad., March 22, 1872.
Died, March 23, „
The cause of death
was shock.
Result, cured.
Ad., Dec. 28, 1872.
Dis.. Aj.ril 17, 1873.
Result, cured.
Result, cured.
Comjyotmd FracHires of
The wheel of a railway waggon passed over
his shoulder, causing a compound commi-
nuted fracture of the humerus and scapula.
Compound comminuted fracture of the hu-
merus.
Cab wheel passed over arm, causing a com-
pound comminuted fracture of the hu-
merus. Patient brought to the hospital
immediately.
Compound fracture of the humerus.
MR. LISTERS COMPOUND FRACTURES.
475
Result of Accident {contirmed).
Wound washed out with 1-20 carbolic
lotion.
Wound washed out with 1-20 carbolic
lotion.
Wound enlarged and syringed out with
1-20 carbolic lotion.
Putrefaction was not avoided. Sloughing oc-
curred to a considerable extent and the dis-
charge had a foul smell. When this was evi-
dent, boracic ointment and boracic lint were
used. The temperature chart cannot be found,
but for some days the tf'm])erature varied
from 100'^ to 103'^ F. On March 23, two
pieces of dead bone were removed. When dis-
charged the wound had healed and the frac-
ture united.
Aseptic course.
Aseptic course. Wound healed about December
20. Fractures found united on December 27.
Sent out with a silicate apparatus on.
In these 19 cases the attempt to eradicate the causes of putrefac-
tion was unsuccessful in 4 instances. It was also unsuccessful in
both the cases in which secondary amputation was necessary. Thus
the attempt failed in 28-5 per cent, of the cases. One case putrefied
after some days because the patient tore off the dressings.
In 2 of the 6 septic cases secondary amputation was necessary ;
necrosis occurred in 1, sloughing of the skin took place in 1, and in
the remaining 2 there was inflammation and abscess formation.
In none of the aseptic cases was any operation necessary. In
only 1 w^as there any appearance of necrosis, and the course of the
others is markedly different in all respects from that of the cases
where putrefaction was not avoided.
the Humerus [accvlpntal).
Arm removed and also loose portions cf
the scapula.
See Wounds of .J<.ints (Xo. 2).
Wound wasiicd out witli 1-20 carbolic
lotion.
See Wounds of Joints, p. 121 (Xo. 11).
The patient was j-utTiring severely from shock
when he was admitted, and he never rallied.
Died from ^Iiock.
rutrefaclion was .n voided, but late in the case a
little pus escai)ed from tiie wound. On probing
it dead bone was felt. This was removed in
June, and tiie wound healed raiiidly. The
hemes were (irmlv united on Ap;il 11.
(SeeT. Chart III., p. 438.)
476
RESULTS OF ANTISEPTIC SURGERY.
I. — Compound Fractures, the
Four compound fractures of the humerus were under treatment
with 1 death from shock.
Of these 1 case was amputated primarily and died, while 3 cases
Compou7id Fractures of
Name and Age
39
40
41
42
C. B., 40 . .
J. H., 16 .
Thomas W ., 17
Jolm S., 34
J. F., 30 . . .
(Septic case.)
John O'H., 28
Andrew Y., 38
Date of Admission
and Discharge ; with
Result
Ad., June 2, 1874.
Dis., Jul}' 6, „
Result, cured.
Ad., June 8, 1877.
Dis., July 16, „
Result, cured.
Ad., Julv 19, 1872.
J)is., Sept. 22, „
Result, healed.
Ad., July 7, 1873.
Dh., Aug. 14, „
Result, cured.
Ad., Oct. 29, 1875.
Dis., Jan. 31, 1870.
Result, in process of
cure.
Ad., Dec. 24, 1875.
Dis., Feb. 11, 1876
Result, in process of
cure.
Ad., March 5, 1878.
Result, cured.
(SecNo. 2G, p.472.)
Injury
A weiji'ht of 30 cwt. fell from a height on to
his forearm, completely crushing it.
Patient's forearm was drawn into a crushing
machine and very badly smashed.
Hand caut^ht in a printing-machine, causing
a compound comminuted fracture of the
humerus. Kadial artery torn across.
Fingers cold and pulseless. Extensive in-
jury of the soft parts. Admitted at once.
Forearm run over hy a vehicle. There was
a small wound communicating with a frac-
ture of both bones. The accident happened
an hour and a half before admission.
Arm caught in machinery. Compound frac-
ture of both bones of the forearm. Kadius
much comminuted. Soft parts much torn.
Compound fracture of the forearm from a
piece of wood falling on it. Seen after two
or three hours.
Patient liad a compound CoUes's fracture as
well as the fracture of the leg.
There were thus 7 compound fractures of the bones of the fore-
arm without a death. Of these, 2 cases required j)rimary amputation.
In one of the 5 cases treated conservatively the attempt to eradicate
the cause of putrefaction was unsuccessful. In 2 of the 5 cases
union occurred satisfactorily ; in 2 union was delayed, and in one it
did not occur on account of the great loss of bone.
If we sum up the results of compound fractures of the extremi-
MR. LISTERS COMPOUND FRACTURES.
477
Result of Accident {continued).
were treated conservatively with good result. The attempt to eradi-
cate putrefaction was successful in each of the 3 cases.
the Forearm {accidental).
Primarj' amputaticin thnuigh the lower
part of the humerus.
Primary amputation above the iiiiddle of
the humerus.
Wounds washed out with i-"20 carbolic
lotion. Some loone fragments of the
broken radius were removed. The
wounds were also mopped out with
chloride of zinc. Splints applied.
Wound enlarged and a solution of car-
bolic acid in spirit injected.
Wound washed out with 1-20 carbolic
lotion.
Wound enlarged and injected with 1-20
carbolic lotion.
Wound washed out witli 1-20 carbolic
lotion.
Aseptic course. A minute superficial sore re-
mained to heal, where the drainage-tubes were,
when the patient was discharged.
Aseptic course. Wound healed by first intention,
except where the drainage-tube was. Here a
small superficial sore remained to heal when
the patient was discharged.
The fingers regained their warmth during the
first twenty-four hours. Putrefaction was
avoided, and the case went on well. So much
of the radius was lost that union could not take
place. The wounds were quite superficial on
August 19, and had healed when the patient
was discharged. (See No. 105.)
Aseptic course. Highest temperature 99-9, pulse
82. Date of healing is not gi\Tn, but healing
was com|)lete and the bones were strong before
the patient left the hospital.
Putrefaction was apparently not avoided. The
wound did very well, but when the patient was
discharged it had not quite healed. Bones
pretty firm. Patient discharged, wearing an
immovable apparatus. (See T. Chart XXIV.)
Typical cciurse. When discharged to be treated
as an out-patient, there was only a small point
to Ileal, and the bones were getting firm. (See
T. Chart XXV.)
Followed a typical aseptic course. The arm had
healed and the splints were left off on April 12.
ties produced by accident and treated by jMr. Lister, we get the
following facts: —
Since 1871 there have been 41 patient.s (42 limbs) admitted into
hospital suffering from compound fractures of the long bones ; of
these 8 died. In 6 the cause of desith was shock and exliaustion,
and death occurred within forty-eight hours after the accident ; in 1
the cause was diphtheria, and in 1 bronchitis and cardiac disease.
478
RESULTS OF ANTISEPTIC SURGERY.
I. — Compound Fractures, the
Of the 42 limbs injured 10 (10 patients) were amputated prima-
rily, and of these four died (all from shock). I need not refer to
these again, as they do not concern the point at issue. There were
thus 31 patients (32 compound fractures) in which conservative
treatment was attempted, and of these 4 died (2 of shock, 1 of diph-
theria, and 1 of bronchitis and cardiac disease) ; but then only 1 of
these deaths (case 4, which died of bronchitis and cardiac disease)
can possibly be supposed to have any connection with the method of
treatment of the wound. Hence, for our present purpose, we have to
consider 28 cases (29 fractures) treated conservatively with one death.
The fatal result in this instance is stated to have been cardiac dis-
ease and bronchitis, but the precise cause does not tell against the
aseptic results, for in this case putrefaction took place. *
Of the 32 limbs treated conservatively, only 2 required secondary
amputation, and one of these patients died of diphtheria, or we may
perhaps put it better, and say that of the 29 limbs (28 patients) under
consideration, only one required secondary amputation, and this case
recovered. One of the remaining 27 patients died of bronchitis and
cardiac disease.
Of the 30 limbs treated conservatively in patients who did not
die within forty-sight hours, the attempt to eradicate putrefaction
Compound Fractures
43
Name ami Age
William S., 18 .
Date of Admission
and Discliarnc ; with
Result
Injury
Ad., Jan. 29, 1872. |Coni])oiiii(I dpprcsscrl fracture of the right
Dis., May 30, ,, i tcm|i(>ral bone. Patient quite sensible on
Result, cured. admission.
MR. LISTER 8 COMPOUND FRACTURES.
479
Result of« Accident (continued).
was successful in 22 instances, and none of these required fuilher
measures ; all healed. But in 8, or 26-6 per cent., the attempt was un-
successful ; of these 1 died, in 2 secondary amputation was necessary,
one of which patients also died of an independent disease, while in
some of the remainder the further progress of the case was unsatis-
factory This is a striking fact, as showing the difference in results
between cases treated aseptically and those treated with antiseptics.
These figures do not, however, rightly represent the present prob-
abilities of rendering compound fractures aseptic, for the majority of
the failui-es occui-red early in the treatment, while of late the greater
number of attempts have been successful. Thus from the end of
1871 till the end of 1875, 18 cases were treated, and of these 6, or
33"3 per cent., ftiiled. On the contrary, from the end of 1875 till
1880, 12 cases were treated, only 2 of which, or 16-6 per cent.,
failed. The chief improvement which has led to this greater success
is no doubt the method of washing out the wound thoroughly by
means of a catheter attached to a syringe — a method introduced
since 1875. The chance of success depends, however, almost entirely
on the nature of the wound and the amount of dirt in it. If it be
complicated and dirty the result is doubtful ; otherwise success is
almost certain.
of the Skull {accidental).
Treatment
Clots removed, and the wound syriiij^ed
out with 1-20 carbolic lotion. Gauze
dressing applied.
The wound remained aseptic, but in a few hours
the patient became restless and comjilained of
pain in his head. He soon became unconscious.
Trephiuin^was tiierefore performed on January
ol, the depressed bone elevated and some frag-
ments of the internal tabic removed. Patient
recovered consciousness after the operation, and
progressed rapidly towards recovery, the blood-
clot lying- exposed in the wound. At one part,
at the time of the ojjeratiou, the bone was felt
bare for some distance, but none separated, and
it was all completely covered on February 22.
The Wound had completely healed cm Mav 2.
Wiien the jialient was discharged, tlie j)ulsa-
tioiis of the brain could be seen to raise tiic
cicatrix. (Sec T, Chart XXVI.)
480
RESULTS OF ANTISEPTIC SURGERV.
I. — Compound Fractures, the
Name ami Ap
44
A:>
George S., 18
J. MeC. (adult)
46
J. McK., 7 .
48
49
51
52
William L., 32
Andrew P., 7 .
G. W. E., 12 .
Gcorj^e II., 3fi .
David McC, 30
A. C, 15
Thomas G., 32 ,
Date of Adniissioii
ami Discharge ; with
Result
Ad., Feb. 12, 1872.
Dis., Feb., 18, „
Besult, in process of
cure.
Ad., March 4, 1872.
Dis., ISIay 2, „
Result, cured.
Ad., June 14, 1872.
])h., July 22, „
Besult, in process of
cure.
Ad., Nov. 15, 1872.
Died, Nov. 17, „
The cause of death
was injury to the
brain substance.
Ad., Sept. 15, 1.S7G.
Dis., Oct. 8,
Result, cured
Ad., April 2, 1878.
7>/s., April 15, ,,
Ncsiilt, cured.
Ad., M:iy 14, 1878.
Died, May 15, „
The cause of death
wasfracture of the
skull, &.C.
Ad., Oct. 3. 1880.
iJis., Oct. 1 8, „
Result, cured.
Ad.,.Ur\. 22, 1880.
Dis., Feb. 9, „
Result, in process of
cure.
.4 rf., April 9, 1!
Di.i., April 20,
Result, cured.
Injury
Compound fracture of the os frontis.
depression.
No
The handle of a windlass struck patient on
the forehead, causing a depressed compound
comminuted fracture of the os frontis.
Fracture of nasal bones. The patient was
conscious when admitted.
Depressed compound fracture of temporal
bone.
Patient fell from a heii>ht of 20 feet, sustain-
ing a compound fracture of the skull.
Patient insensible, pupils dilated, surface
cold, had several convulsive fits before
admission.
Compound fracture of temporal and frontal
bones. Bleeding" from the ear and nose.
Run over by the wheel of a c.nb, head
markedly flattened.
An iron gate fell on his head detaching
nearlj^ half the scalp, which was hanging
down. Bone fissured.
Patient fell 10 feet, striking his head and
causing an extensive compound ('ommi-
nuted fracture of the skull. Patient insen-
sible, but muttering and restless.
Struck on the head by a bottle, causing two
incised wounds and fissure of the skidl.
Patient drowsy, but sensible.
Fell on his head from a height of 35 feet.
Large scalp wound, fracture of parietal
bone, and other injuries, no depression.
Patient quite insensible when admitted
into hospital.
Fell 68 feet, and struck his forehead, receiv-
ing a compound fissure of the frontal bone.
Patient sensible ; other bruises present.
MR. LISTERS COMPOUND FRACTURES.
481
Result of Accident [continued).
Wound injected with 1-20 carbolic lotion,
and for the most part stitched.
Wound injected with 1-20 carbolic lotion,
depressed bone elevated, and portions
of loose bone and of the internal table
removed.
Wound injected with 1-20 carbolic lotion,
and left quite oi)en.
Comminuted portions removed, and de-
pressed bone elevated. Wound
washed out with 1-20 carbolic lotion.
Wounds injected with 1-20 carbolic lo-
tion. Ears stufl'ed with gauze.
Wound thoroughly washed out with 1-20
c.irbolic lotion, catjfut drain and numer-
ous horsehair stitches.
A portion of loose bone was rcmovdl, and
the wound was syrinj;cd out, and left
open.
Two small pici'csdf the outer tabic were
rcnujved and the wound was washed
out with 1-21) carbolic lotion.
A portion of bone was loose, and was re-
moved, wound washed out witii 1-20
carbolic lotion.
WoHinl washi'd out wiili 1-20 carliolii
Inii. n.
Aseptic course. No suppuration, the wound heal-
ing bv first intention and organisation of blood
clot. '
Aseptic course- The Avound had quite healed on
March 16. As there was slight redness and
pain at one part of the scar, it was opened up
on March 27, and one or two minims of jnis
escaped. This had soundly healed by April 19.
There was an elevation of temperature on
March 7, apparentlv due to derangementx>f the
bowels, as it subsided at once on administering
a laxative. (See T. Chart XXVII.)
This case followed an aseptic course till July 12,
when, probably owing to the restlessness of
the patient and consequent displacement of the
dressings, the wound was found to have be-
come putrid. By tliis time, however, the
deeper parts had closed. When discharged
there was stiU a small suppurating wound, and
a portion of the os frontis could be felt to be
bare.
Absolute insensibility, with occasional convulsive
attacks, continued till his death, about 36 hours
after the injury.
Aseptic course, except that an abscess formed on
the side of the head behind the eye. Everj'-
tliing had healed, and was apparently sound
when the patient was discharged.
Aseptic course. The woimd healed entirely by
tirst intention, except at one point where a
little piece of horsehair draiti was employed.
On April 12, there -were just three tiny points
to heal. A collodion dressing was ap])lied.
(See T. Chart XXVIII.)
Th" patient never recovered consciousness, and
died about 27 hours after the accident. The
skull was found to be very extensively frac-
tured and ha'niorrliage had <icciirr('d in various
places but no lesion of the brain was found.
As ptic course. On Octolter \'i\ two additional
|ii('ces of bone were rtnuivcd. (See T. Chart
XXIX.)
Aseptic course. The wound had .'dniost healed
when the patient was dischargeil, to be treated
as ati out-|iatient. (See T. Chart XXX.)
Aseptic cour.se. Tiui wound h.id qnile iie.iled
when the patient w.is discli.irucd.
1 I
482
BESVLTS OF ANTISEPTIC SURGERY
xvm
XK
XZ
m
:m em em em em em em em e
M EM EM EM EM EM EM EM Et
XXI
xxu
Tkmperatitkk Charts oh' Mr. Listek's Cases op Compound Fractukk.
MR. LISTERS COMPOUND FRACTURES.
J 83
M EM EM EM EM EM E
—■■■— ■■■■■■■
MilililMIBHilHWMIHIIlllW
IHljHHSMHI
XXV
XXMIL
xjLvar
EM EM EM EM EM EM eH tM
^■■■■■■■■■■■■■■^
■■■■■■■■■■■■■■^
{■■■^■■■■■■■n
m^m^mmm^m
MX
:■■■:«:■
mwmmmmmmmmwk
L'KMPERATrUE CUAIiTS OF M R. LiSTEKS C'ASE< OF COMPOUND ]• ItACTlKE ( <Y////.)
1 I 2
484
RESULTS OF ANTISEPTIC SURGERY
There were thus 11 cases of compound fracture of the skull with
two deaths, both due to the nature of the injury, and both occurring
within forty-eight hours. In all the 9 cases which survived putre-
faction was avoided, and the result was good.
The whole result of iNIr. Lister's hospital practice in regard to
compound fractures produced accidentally since 1871 is therefore as
follows : — 52 cases of compound fracture of the skull and long bones
(53 fractures) were treated with 10 deaths.
Leaving out of consideration here all the cases which died within
forty-eight hours, we have 44 cases (45 fractures) with 2 deaths,
1 from diphtheria and 1 from bronchitis and cardiac disease.
Or, taking the facts in another way, and, as is generally done,
leaving out cases requiring primary amputation, Ave have 42
cases (43 fractures) treated conservatively with 6 deaths ; and
omitting also cases which died within 48 hours, and which
have no bearing on the point at issue, we have 38 cases of
compound fracture of the skull and long bones (39 fractnres) with
2 deaths, 1 of these deaths being certainly independent of the wound.
In 31, or 81'5 per cent., of these cases the attempt to eradicate the
causes of putrefaction was successful, and all of these cases re-
covered, i.e., 31 compound fractm^es of the skull and of the long
bones were treated aseptically without a death and, in the case of
the limbs, without necessity for further operation.
I now propose to consider the compound fractures made by the
II. Compound Fractures
Compound Fractures of
54
Name
and Age
James
M.,
13 .
Alexander
W.,
37
Frances (J.
, 54 .
Date of Admission,
OpiTatioii and Dis-
cliarge ; with Result
Ad., Jan. 22, 1873.
Date of discharge
not given.
Result, cured.
Op., June 18, 1873.
Result, healed.
See No. 6, p. 42().
Result, healed.
Injury
Anchylosed knee-joint. Knee bent at right
angles.
Ununited fracture of the femur-joint above
the knee-joint.
Ununited fracture of the nnck of the femur.
MR. LISTERS COMPOUND FRACTURES.
485
surgeon, and I would remark that Mr. Lister's osteotomies were in
no sense of the word subcutaneous. They were real compound
fractures ; the wound in the bone communicated freely with the
external world and a drainage-tube in most cases kept up this
communication after the operation. In some instances the bone was
simply chiselled partly through and then broken ; in others, portions
of the bone were removed. I have not included in this list exci-
sions of joints for disease, partly for the reasons stated on p. 380, and
also because in almost all the cases of diseased joints, sinuses are
present before the patients come into hospital, and therefore the cases
cannot as a rule be treated aseptically : 1 or 2 cases where a
joint was anchylosed, and where a wedge-shaped piece of bone was
removed, in other words where a compound fracture was produced on
a healthy bone, are included.
From these cases the element of shock is excluded, and there-
fore we ought to have results comparable to the 38 cases of compound
fracture with 2 deaths ; and if these deaths were really independent
of the wound, we ought here to have no deaths at all. Here also
the certainty as to the ultimate result ought to be greater and the
character of the results better ; for here we have merely to exclude
the causes of fermentation, whereas in the other cases we had to
destroy those ivhich had entered. In other respects they are
comparable injuries, and, therefore, at the end I shall sum up all the
compound fractm'es together, whether they have been made by the
surgeon or have occurred accidentally.
MADE BY THE SuilGEON.
the Fenntr (^Surcjeon).
A wcili,'c-sli;ij>cd piece of lione was re-
llioveil, anil tlic, le;;' was Ijrinijilit
straitclit. Iiicisiou made over the seat
of fracture.
Ends of bones refreshed by KOi'o'^ '""1
lianiincr. Wound left open.
Operated on.
Ty|iii'al aseptii; tdurse. On Filiruary 'l all the
stitches were removed, and every thinj; was
healed, except wliere the ihainaj,a'-tube was.
All soundly healed (ni Feliniary 11.
Aseptic course. Cimipletely healed during
Auf;ust. The temperature was taken once
daily, and was only once up to 100"^. iNo
union. Sec Nos. 57 and 58.
Aseptic cour.se. (See T. Chart I A'.)
486
RESULTS OF ANTISEPTIC SURGERY.
II. Compound Fractures
Name and Age
58
59
()0
01
(i2
G3
r,4
Alexander VV.,
38 ... .
Alexander W.,
38 ... .
Thomas D., 37
Richard K., 12 .
Peter M.,30
C. VV. Y., 9
Date of Operation
aud Pischarftx' ;
with Result
Thomas D., 38 .
Mary McD., Ifi.
Op., March 6, 1874.
Result, healed.
Op., July 17, 1874.
Dis., Sept. 21, „
Result, cured.
Op., July 23, 1875.
Dis., Nov. 23, „
Resiilt, healed.
Op., Oct. 4, 1875.
Bis., Dec. 14, „
Result, cured.
Op., Feb. 19, 1876.
Bis., July 27, „
Result, cured.
Op., March 14, 187G.
Dis., Oct. 14,
In process of cure.
Op., July 19, 1870.
Bis., Sept. 20, 1877.
In process of cure.
0/5., July 15, 187r).
Bis., Feb. 7, 1877.
Result, cured.
Injury
See No. 55. Fracture still ununited.
See No. 57. Fragments still ununited.
Ununited fracture of femur about its middle,
of eleven months' standing. Various me-
thods of treatment tried.
Aggravated knock-knee on one side.
Ununited fracture of the femur about ten
inches belov/^ the great trochanter. Of ten
mouths standing.
Badly united fracture of the left femur just
below the trochanters. Fracture occurred
eighteen months previously. If inch short-
ening.
Sec No. 59. Fracture still ununited.
Double knock-knee. Patient coulil hardly
walk. The deformity commenced two
years previously, after a fever.
MR. LISTER'S COMPOUND FRACTURES.
487
MADE BY THE SuRGEON (contimied) .
Similar operation to the former. Frag-
ments drilled in two places and iron
pegs driven in. Two wounds made.
Drainage-tube inserted.
A similar operation was again performed,
and the leg was put up in plaster of
Paris at once. (Intermediate amputa-
tion).
Ends of bone gouged,
inserted.
Drainage-tubes
An incision was made above the con-
dyles of the femur down to the bone.
Periosteum detached, and a wedge-
shajied piece of the femi;r removed.
Drainage-tubes inserted.
Incision on outer side of thigh. Ends of
botie removed. Bones drilled and tied
together with silver wire.
Incision on the outer side of the thigh
over the seat of fracture; bone divided ;
limb brought straight. Ends of bone
refreshed and tied together with silver
wire.
Ends of bones refreshed and tied together
with silver wire.
A wedge-shaped piece of bone was taken
out of each femur on the same day.
(Sec No. 60.) Drainage-tubes in-
: sertcd.
Remarks
The pegs became loose and were removed on ^lanh
16. The wound on the inner side healed April
29, and the other soon afterwards. Limb kept
in plaster till -June 8, and put up again till
July 16, but still no union. The temperature
was once up to 100° (100-1), on the moiniug
after the operation.
Putrefaction occurred here probably during the
application of the plaster. As the temperature
was going u|), Mr. Lister thought it best to
amputate. This Mas done on July 22, and
the wound followed a typical aseptic course,
healing entireh' by first intention except where
the drainage-tube was.
Aseptic course. The blood-clot became organised
as usual, and the gaping wound had completely
cicatrised on September 12, without any pus-
formation. Union had not occurred when the
patient left hospital, wearing an immovable
apparatus. (See T. Chart XXXI.) See No. 63.
Tj-pical aseptic course. No suppuration. Wound
completely healed on November 14. Highest
temperature was 99"6°. When seen some
weeks after his discharge the femur was quite
firm and the limb straight.
Aseptic course. Put up in plaster of Paris in
April. Apparatus taken down on July 5.
Bones united. Wire removed. (See T. Chart
XXXII.)
A good deal of constitutional disturbance followed
the operation ; the wound suppurated and ab-
scesses formed. When the patient was dis-
charged a small sinus remained unhealed. The
femur was quite firm and the leg straight, and
only ^ in. shorter than the other. One or two
small pieces of bone came away. Ultimately
healed.
Aseptic course. Patient was kept in hospital
having various immovable apparatuses applied
at intervals, but when discharged there was
still a little mobility. The silver wire was left
in, and the fragments ultimatelv united without
further operation. (See T. Chart XXXIII.)
Aseptic course. The right leg had completely
healed at the end of -Vugust, and the loft almost.
Fioth limbs uere put u|> in plaster of Paris on
August MO. This was taken down on November
oO, when both hones were found to be united
(See T. Chart XXX IV.)
488
RESULTS OF ANTISEPTIC SUROERF.
II. Compound Fractures
Name and Age
60
68
09
70
72
Adam S., 6 .
JohnT.. 11 .
Emma P., 9
George E., 12
Thomas E., 35
Jane D., 50 . .
Beatrice J., 14 .
Frank J., 7
Date of Operation
and Discharge ;
with Kesult
Op., Aug. 1, 1876.
iJis., Dec. 4, „
Result, cured.
0/)., June 29, 1877.
Z>/»-. durin.i^ autumn.
Result, cured.
Op., Nov. 20, 1877.
IJis., July 27, 1878.
Result, cured.
Op., Jim. 29, 1.S79.
Dls., Dee. 14, „
Result, healed.
Op., March 19, 1879.
J)is. May 15, „
Result, cured.
Op., April 9, 1879.
Uis., J une 30, „
Result, healed.
Op., May 16, 1879.
IJis., July 8, „
Result, cured.
Op. May 21, 1879.
Dis., J lily 8, „
Result, cured.
Injury
Aggravated knock-knee on one side.
Both knee-joints ancliylosed at an acute
angle — tiie result of j)revious disease.
Left knee-joint anchylosed nearly at a right
angle.
Ununited fracture of the neck of the femur
of six weeks' standing (extracapsular).
Double iSL'ini valgum.
Ununited fracture of the femur.
Genu valgum on the right side.
Genu valgum on both sides.
MR. LISTERS COMPOUND FRACTURES.
489
MADE BY THE SuRGEON {continued).
Treatment
Similar operation to No. 64. Drainage-
tube inserted.
Left leg operated on. Only so much
bone removed as was necessary to ob-
tain a straight position of the limb.
Portions of the end of the femur were re-
moved, and the leg was got straight
after division of the hamstring ten-
dons. Horsehair drain.
A long incision was made on the outer
side of the thigh over the great tro-
clianter. The fragments refreshed and
two drainage-tubes inserted. Long
splint.
MacEwen's operation on both thighs at
the same time. Drainage tubes in-
serted.
Ends of fragments refreshed and tied
together with silver wire.
MacEwen's operation on the right thigh.
Drainage-tubes inserted.
MacEwen's operation on both limbs on
the same day. Drainage-tubes in-
serted.
Aseptic course. Wounds quite superficial and
almost healed on September 1. The femur was
quite lirm on September 4, but there was still
slight divergence outwards. This was due to
want of caie in adjusting the splints during
the holidays.
Aseptic course. The greater part of the wound
healed by tirst intention, but two sinuses were
still unhealed in the beginning of September
when Mr. Lister left Edinburgh. I hear that
the patient left the hospital soon afterwards,
with the woimds quite healed and able to move
his knee very slightly (a movable knee-joint
was aimed at in the first instance).
Aseptic course. Wound healing by first intention
except where the drain was. The drain was
removed on January 12. A small abscess
formed on the outer side of the knee, and was
opened on February 5. A minute sinus remained
here for a long time, the wound being soundly
healed and the bones firm. It healed a few
days after the patient was sent to a convalescent
home.
There was considerable constitutional disturbance
after the operation, and the temperature at
times Avas as high as 101'G°. A little suppura-
tion occurred from the wound, but the greater
part healed by first intention. A little bit of
loose dead bone (apparently a chip from the
operation) was removed on November 11, and
then the sinus at once closed. Union did not
occur. From the high temperature and the
suppuration it is probable that some ferment
had got in, but the discharge was not examined,
and it never had anv smell. (See T. Chart
XXXV.)
Aseptic course. Both wounds had healed at the
end of April. Union was then complete.
Patient began to walk on Mav 5. (See T.
Chart XXXVI.)
Aseptic course. No suppuration. Wound healed
about May 15. Patient was discharged wearing
an apparatu.s, but union did not occur.
Aseptic course. Healed about .June 5. Splints
removed and bones united on June 2^. Began
to walk on June 29. (See T. Chart XXXVII.)
Asc])tic ciiurse. l?olh wounds had healed by
Jun:; 10. Union jicrfcct on Juik' 'M). Joints
freely movable. (See T. Chart XXXVIII.)
400
RESULTS OF ANTISEPTIC SURGERY.
II. Compound Fractures
No.
Name and Age
Date of Operation
and Discharge ;
with Result
Injury
73
Lydia \V., 9 .
Op., July 9, 1879.
Dis., Aug. 19, „
Result, cured.
Genu valgum on right side. See also No. 87.
74
Ethels., 5 . .
Op., Oct. 15, 1879.
Dis., Dec. 14, „
Result, cured.
Double genu valgum.
75
John M., 15 .
Op., Oct. 22, 1880.
Dk, Jau. 3, 188L
Result, cured.
Genu valgum on the right side.
76
Henry D., 17 .
Op., Nov. 5, 1880.
Dis., Jan. 7, 1881.
Result, cured.
Bony anchj-losis of knee-joint of eight years'
standing : leg at right angles to the thigh.
We have thus 23 cases in which compound fractures of the femur
have been made by the surgeon (27 compound fractures). In all
but 3 cases there was a typical aseptic course, i.e., the patient ate as
well and was as well in every respect as if he had not been operated on,
while there was no suppuration from the deeper parts of the wound,
Corajwuncl Fractures
77 John C, 44 . . Op., Aug. 28, 1872. Ununited fracture of both bones of the leg.
Result, healed.
79
80
81
John C, 45 ,
John C, 45
Eliza L., 23 ,
Eliza L., 21 .
Op., July 30. 1873.
Result, healed.
Op., Jan. 15, 1874.
JHs.. Sept. 3, „
Result, cured.
Op., June 6, 1874.
J)is., Aug. 1.3, „
Result, cured.
Op., March 17, 1«75.
Exact date of dis-
charge cannot be
ascertained.
Result, cured.
Former case (No. 77). Still ununited.
Former case (Nos. 77 and 78). Tibia still
ununited.
Badly united Pott's fracture. Leg much
everted.
Patient (Ni). 80) had used her foot loo freely,
and there was some return of the deforniit\'.
MR. LISTER'S COMPOUND FRACTURES
491
MADE BY THE SuRGEON (continued).
MacEwen's operation,
inserted.
Draiuai;e-tube Aseptic course. No date of healinsr. Allowed to
get up fur the first time on August 12. Union
then perfect and wound healed.
M.icEwen's operation on both sides.
Drainage-tubes inserted.
MacEwen's operation on the right side.
Wedge-shaped piece of bone removed.
Horse-hair drain.
No local disturbance, but the temperature rose a
little for a day or tAvo, being once as high as
101°. The child, however, was quite well. On
November 6 one wound Avas healed and the
other ne 'riv so. Both legs seemed to be firm
at that time. (See T. Chart XXXIX.)
Aseptic course. Wound superficial on November
10, and boracic dressing applied. Patient got
up on December 4. (See T. Chart XL.)
Aseptic course. On December 9 all healed except
two spots where the drain was. Patient got up
on January 2. Seen last on March 20, when he
could walk well without anv support. Bones I
quite firm. (See T. Chart XLI.) I
and as a rule none at all from the superficial part. In one case
where putrefaction occurred, secondary amputation was performed as
being the safest treatment and also the best when the difficulty in
getting union and the shortening of the limb were taken into
account.
of the Leg [Surgeon).
Ends of the bones refreshed and l)rought
into good position. Wound left open.
Similar operation.
Similar operation. Iron
driven into the tibia.
pegs were
Fibula divided obliquely. Foot brought
straight. Wound left open. Dupuj-
tren's splint.
Similar treatment.
Aseptic course. On November .5 the limb was
put up in plaster of Paris. This was reapplied
several times till July, 1873, but union did not
take place. See No. 78.
Aseptic course On September .5 the wound was
small and quite superficial. The fibula united,
but the tibia did not. See No. 79.
Aseptic course. On March 12 union was found
to have occurred, and the pegs were removed.
The rest of the wound had healed. The patient
was, however, kept in ho.spital for some time.
Aseptic course. Wound had herled and the
bones were apparently firm when the patient
was discharged.
Aseptic course. Kept loiigor in an apparatus.
On this occasion the cure was permanent. (See
T. Chart XLI I.)
4!)2
RESULTti OF ANTISEPTIC SURGERY.
II. Compound Fractures
82
83
84
85
80
88
89
90
Name and Age
Martlia C, 28
William M., 3(3
Martha C, 28
FinlayMcD.,29.
Date o" Operation
anil Discharge ;
with Result
Alexander A., 23
Lydia VV., 9
Henrv B., 32
Frederick A., 2G
Joseph B., 2.
O/)., All-. 18, 1875.
Din., Oct. 2, 1876.
Result, healed.
Op., Dec. 21, 187o.
DIs., March 2, 1876.
Result, cured.
Op., Feb. 27, 1876.
Result, cured.
0/j., Jan. 16, 1877.
Dis., June 9, „
Result, cured.
Op., July 19, 1877.
Dis., Oct. 13, „
Result, cured.
Oj>., July 9, 1879.
Di.^., Aus. 19, „
Result, cured.
0/3., Dec. 12, 1879.
Dis., March 31, 1880.
Result, cured.
Op., Nov. 0, 1879.
Dis., Dec. 16, 1879.
Result, cured.
Oj>., June 18, 1880.
His., July 15, 1880.
Result, eured.
Injury
Congenital deformity of right foot. Invcr-
f-ion of foot, the inner surface of which
formed an angle of 140° with the axis of
the leg.
Badly united fracture of the leg with dis-
lilaccment of the font backwards. Of
fourteen mouths' standing.
See case No. 82.
Badly united fracture of both bones of the
leg, just below the tuberosity of the tibia.
Leg bent inwards.
Ununited fracture of both bones of the leg at
the junction of the middle and lower thirds.
Cf fourteen weeks' standing.
Rickety deformity of one leg
73.
See also No.
Badly united
everted.
Pott's fracture. Foot much
Patient was admitted a fortnight previously
with simple fracture of both bones of the
leg. A fragment of the tibia projected
under the skin, causing great pain and
threatening to protrude.
Rickety deformity of both legs.
MR. LISTERS COMPOUND FRACTURES.
493
MADE BY THE SURGEON {continued).
Treatment
Remarks
Fibula cut through and a wedge-shaped
portion of bone removed from the tibia.
Extensor tendons divitled. Bones tied
together 'iv silver wire. Foot brougtit
into straight position.
Tiljia and fibula divided bv lateral inci-
sions. Foot brought straighL Du-
jjuytren and horseshoe splints.
End-s of fragments refreshed. Similar
after-treatment to that formerly
adopted.
Fibula cut across. Wedge-shaped piece
of bone removed from tl'C tibia. A
portion of the fibula cut away. Leg
straightened, and wounds left open.
Incisions over each bone, and the frag-
ments refreshed. Iron pegs driven
iuto the fragments of the tibia.
Incisions over the bon^^s which were then
cut across. Drainage-tubes inserted.
No stitclies.
An incision was made over the site of the
former fracture, and the libula divided
obli(|uely. Foot inverted by means of
pulleys. Drainage-tubes inserted.
Dupuylren's splint.
Mr. Lister cut down on and removed the
projecting portion, thus causing a com-
pound fracture.
Incisionn over the tibia and fibula.
Hones divided. Wounds left r)peri.
]5oth legs oper.ated on.
Aseptic course. Wounds superficial on September
18. When seen in Februarv, 1876, the b(me
was still ununited. See No. 84. (See T. Chart
XLIII.)
Aseptic course. Bones firmlj' united and only a
little speck to heal on February 1.
As?ptic course. On this occasion imion took
place, but the dates of union and discharge are
not given in the note books.
Aseptic course. Tibial wound found healed on
March 1, and the fibular on March 3. Plaster
of Paris removed on March 10, and the bones
found to be firm. It was reapplied till
May 1, when it was finally left otf. the bones
being quite firm and strong. (See T. Chart
XLIV.)
Aseptic course. The temperature rose on one
occasion as high as 99-8°. Iron pegs removed
on September 1, and wounds healed a few days
later. On October 4 the bones were lound to
be quite united.
Aseptic course. Date of healing not given. Pa-
tient allowed to get up for the first time on
August 12. Union then perfect and the wounds
quite healed.
Aseptic course. Wound i|uite suiterficial and
boracie dressing ajjplied on January' IG. Splint
left off anfl patient allowed to get up on Feb-
ruary 24. There was a little ])ointing of the
toes, which was overcome by elastic force. (See
T. Chart XLV.)
Asejitic course. On Xoveuiber 17 the wound was
quite suiicrlicial, and boracie <lressing Wii-s ap-
I)lird. riic wound was healed and the bones
firm when the patient left the hospital.
Aa-'ptic course. No date of healing. Wounds
quite healed and the bones firm wlicn tiie i)a-
tiiut was disciiarged. (.See T. Chart XL VI.)
494
21ESULTS OF ANTISEPTIC SURGERY
II. Compound Fractures
No.
91
Name and Age
Date of O))eratioii
and Discharge ;
with Result
Ill jury
Jessie C, 2\\ .
Op., Oct. 29, 1880.
DIs., Dec. 20, „
Result, cured.
Bad rickety deformity of both leg.*5.
Fifteen patients with compound fracture of the leg were treated
without a death; and in these cases there were 31 separate compound
92
93
94
Henry F., 1(5
William A., 71
Elizabeth H., 22
Op., Feb. 4, 187.5.
Dh., March 2, „
Result, cured.
Op., June 1, 1877.
L>is., Aug. 6, „
Result, cured.
Op., Feb. 12, 1879.
Ms., April 12, „
In process of cure
Compound Fractures of
Simple fracture of the clavicle ; a fragment
projecting under the skin, cau.sing great
pain and interfering with the adjustment
of the fracture.
Unreduced dislocation of the acromial end of
the clavicle. Of ten weeks' standing.
Patient cannot use the arm well.
Cervical rib pressing forward the brachial
plexus and causing great pain. Patient
very hysterical.
There were 3 compound fractures of the clavicle without any bad
9o
90
Alexander S.,r)0
Jame.s McB., 48
John 15., 14
Op , Feb. 9, 1872.
JJis., Sept. 5, „
In process of cure.
Op., Feb. 12, 1872.
DLs., Oct. 10, „
Result, cured.
Op., Dec. 6, 1872.
DIs., Feb. 11. 187.S.
Result, cured.
Compound Fractures of
Ununited fracture of the humerus of two
years' standing. Various methods of treat-
ment had been previousl}* adopted.
Ununited fracture of the humerus .at the
junction of the upper and middle thirds.
Of si.x months' standing.
Fracture of lower end of humerus with dish
cation. Of five months' standing.
MR. LISTER'S COMPOUNL FRACTURES.
495
MADE BY THE SURGEON [continued).
Both bones in both legs divided, and
wedjre-shaped portions removed from
the tibia. On the ri^ht side the bones
were divided in two places.
Aseptic coarse. Wounds superficial and spray
stopped on November 6. Exact date of healing
not given ; it was apparently about the end of
November. Splints removed and the patient
allowed to walk on December 14. (See T.
Chart XLVII.)
fractures made. In no instance did any local or constitutional
disturbance follow the operation.
the Clavicle (Stirgeon).
Mr. Lister cut down and removed this
loose portion, thus converting the case
into one of compound fracture. Drain-
age-tube inserted.
Articular surfaces removed and the ends
of the bone tied together with silver
wire. Wound left open.
Mr. Lister cut down and divided the
clavicle. Drawing aside vessels, &c.,
he removed the rib, which was attached
to the sixth cervical vertebra, and arti-
culated with the first and second ribs
in front. Clavicle tied with silver wire.
Drainage-tubes inserted.
Aseptic course. The wound had healed and the
bone firmly united on March 6.
Aseptic course. Wire removed on July 1.5.
Healed on July 24. Union was perfect and the
movements were greatly improved when the
patient left hospital. (See T. Chart XLVII I.)
Aseptic course. Wound healed by first inten-
tion, except where the drainage-tube was.
Wound quite healed on March 12. The clavicle
did not unite firmly till September. Wire re-
moved during November. (SeeT. Chart XLIX.)
symptom.
the Humerus (Surgeon).
Ends of fragments s.awn off, bones tied
together by silver wire. Wound left
open.
Ends of fragments refreshed and tied
together with silver wire. Drainage-
tube inserted.
Excision of elbow-joint b}' a longitudi-
nal incision.
Aseptic course. Wire removed during March, and
the wouikI quite healed on April 4. The bone
was almost, but not absolutely, firm, and the
patient was discharged wearing a silicate appa-
ratus.
Aseptic course. The greater part of the wound
healed typicaliy, but a sinus remained around
the wire leading down to bare bone. On June
3, osseous union was com|)]('te. Wire removed
on Auirust 2.'?. When discharged tliere was
still a sinus leading down to bare bone.
No constitutional disturbance. A smjill abscess
formt'd on the outer part of the limb, and was
opened on December 20. It h.-id healed on
January 20. The opera! ioti wound had en-
tirely healed on January (>. except a minute
su])erfi<'ial crack with the healing of whicli the
movement of the arm seemed for some time to
interfere. The movement was good when pa-
tient was discharged.
496
MESULTS OF ANTISEPTIC SURGERY.
II. Compound Fractures
98
99
100
101
102
103
Name and Ago
Peter B., 1 1.
Donald McL. 45.
James J., 24
John N., 15
Jessie S., 14
Edward W., 12
Date of Oijeration
aiirl Discharge ;
with Result
0/j., Dec. 2, 1872.
7>?s., Feb. 11, 1873.
Result, cured.
Op., Nov. 14, 1874.
IHs., Feb. 28, 1875.
Result, cured.
Op., Dee. 15, 1875.
iJis., June 8, 1876.
In proce-^s of cure.
Op., Nov. 27, 1875.
iJis., Jan. SI, 1876.
Result, cured.
Op., Mis. 21, 1875.
Date of discharge is
not given.
Result, cured.
O/)., Jan. 15, 1879.
In process of cure.
Injury
Similar injury to that in No. 97.
Ununited frapture of humerus a little above
its middle. Of fifteen months' standing.
Fracture of loAver end of humerus, with
inability to use the arm. Done six weeks
previous!}".
Badly united fraeture of the humerus, about
its middle, the arm being bent inwards.
Osseous anchylosis of the elbow-joint in the
straight position, the result of old frac-
ture.
Badly united fraeture of humerus. See
Operations on Joints, No. 18, p. 432.
Thus we have 9 compound fractures of the humerus without
Comj)ound Fractures of
104
105
106
107
108
John McI. 34
Thomas W., 14.
Alexander — , 26
J. McJ., .30
James S., 53
Result, cured.
Op., May 3, 1873.
JJis., Nov. 20, „
Result, cured.
Op., Nov. 10, 1875.
Result, cured.
O/}., Jan. 15, 1876.
JJIs., April 13, „
Result, cured.
O/)., Jan. 26, 1877.
])is, June I '.I, „
Result, cm 0(1.
Ununited fracture of olecranon. See Opera-
tions on Joints, No. 3, p, 426.
Ununited fracture of radius. See No. 38, p.
476.
Dislocation of the head of the radius back-
war Is. See 0|)erations on Joints, No. 10,
p. 428.
Ununited fracture of the radius : of sixteen
months' standing. Had been previously
operated on by ancither surgeon. The ends
of the bones were not in contact.
Ununited fracture of llie radius : oftwenty-
twii weelis' standintc.
MR. LISTERS COMPOUND FRACTURES.
407
MADE BY THE SURGEON {continued).
Exci>ion of elbow-joint by a longitudinal
incision.
Ends of fragments refreshed and tied to-
gether witli silver wire. Wound left
open.
Excision of elbow-joint by longitudinal
inci:jiou.
Bone divided by hammer and chisel and
brought into proper pi sition. Drnin-
age-tulie inserted and plaster of Paris
applied at once.
Exc'.-ion of elbow by H-incisiou.
Remarks
Aseptic course, except that the drainage was
not good for the first day or two. The wound
had completely healed on January 27. Move-
ments good wtien discharged.
Aseptic course. Wound quite healed on Decem-
ber 27. Union was complete and wire removed
on February 27.
The woimd went on well till the Christmas holi-
days, wlien it putretied. After that an abscess
formed in the upper arm. In Marcli onl}' two
sinuses remained to heal. It is not stated
wiiether the.-e had com] letely healed when pa-
titrnt was discharged. Movements fair.
Aseptic course. The wound had completely healed
on .January Iti. The bones were lirui when
patient was discharged.
Aseptic course. The incisions were quite
healed on September 2o. Movements good.
(See T. Chart L.)
Aseptic course.
any bad results.
the Forearm ( Suryeon).
A piece of bone was cut out of the ulna
to allow the ends of the radius tocirme
into contact. Tlie ends of tiie radius
were refreshed Fragments tied to-
gether by silver wire. Lett open.
Ulna divided aixl a portion removed.
The ends of tlie radius refreshed.
Fragments tied togetlier witli silver
wire. Wounds left open.
Ends of radius refreshed. A piece cut
out of the ulna. Fragments tied to-
getlier with silver wire. Wounds left
open.
Aseptic course.
Aseptic course. Plaster of Paris applied on July
28, when both wounds were healed. Uenioved
on November 17, when union was complete.
Wires also i-emnveJ on that day. Seen again
in March, 1874, when the arm was strong,
and in every way perfectly useful.
Aseptic course.
Aseptic course. The wounds had healed and
union was complete when the patient was dis-
charged.
Aseptic course. Both wounds had healed in six
weeks without any pus formation whatever.
Plaster of Paris was a|)plied on March 3.
Apjiaralusremoved on June 2, wlien union was
complete. Wires removed on that dav. (See
T. Chart LI.)
K K
498
RESULTS OF ANTISEPTIC SURGERY
II. Compound Fuactures
109
110
Name and Age
William B., 45
Johu H. 28
Date of Operation
anil Discharfre ;
with Result
Op., March 20, 1879.
Result, cured.
Op., Jan. 14, 1881.
iJis., March 5, „
Result, cured.
Injury
Ununited fracture of the olecranon. See
Operations on Joints, No. 17, p. 432.
Ununited fracture of both bones of the fore-
arm, the result of a machine accident
eleven months' previously.
In all there were 7 cases of compound fracture of the fore-arm with-
in
Maggie C, 17
0/>., April 1, 1875.
l)is.. May 12, „
Result, improved.
One ease of com-
pound fracture of
the lower jaw,
which did well.
Coiripound Fracture of
Anchylosis of one side of the jaw. Jaws
tlrmlv closed. The result of old necrosis.
Following the example of most writers who discuss the
results of compound fracture, I shall now leave out of consider-
ation the cases in which primary amputation was performed,
and also those which died within forty-eight hom-s. The
following result will then be obtained. Since the end of
1871 up to the present time Mr. Lister has had under bis care
95 ^ patients affected with compound fractm-es ; of these 95
patients only 2 died. (The number is apparently 97, but 2
patients are each counted twice.) I may tabulate the result
as follows :
Tart injured
No
of cases
No. of ileaths
Femur .
26
1
Bones of leg
34
1
Clavicle
3
—
Humerus
12
—
Fore-arra
12
—
Skull .
9
—
Lower jaw
1
—
Total No.
fracture
of
Secondary
amputations
1
50
2
12
_
16
—
9
—
1
—
Total .
97
121
A patient on whom an operation has been performed, whose wound has
healcil, and on whom a second operation has then been done, is, of course
reckoned as two separate cases
ME. LISTER'S COMPOUND FRACTURES.
49i>
MADE BY THE SURGEON {continued).
Treatment
Remarks
Incisions over each bone. Fragments
refreshed and tied together with silver
■wire. Wounds left open.
Aseptic course. (See T. Chart XI., p. 439.)
Wounds superficial and spray discontinued on
Januarj' 31. Silicate apparatus applied on
February 7. Wires removed March 16.
Union satisfactory. (See T. Chart LII.)
out any bad result. (There were 11 distinct compound fractures.)
the Lower Jaio {Surgeon).
An incision was made behind the ramus
of the jaw on the anchylosed side, and
the condyle of the jaw was cut through.
The wound was almost absolutely healed on April
21, when boracic dressings were applied. A
Avedge was kept between the teeth, and when
the patient was discharged she could open her
mouth without aid for half an inch. When
seen in July her condition had much improved.
It may, perhaps, be more convenient if I separate the
cases of accidental compound fracture from those made by
the surgeon. The following is the list of the accidental ones : —
Boue
No
of cases
Xo
of death
Femur
3
1
Leg .
19
1
Humerus .
3
—
Fore-arm .
.5
— -
Skull .
9
—
Secondary
amputations
Total
39
The following is the list of those made by the surgeon:—-
Bone
No. of cases
No
of fractiu-cs
No. of deaths
Femur
23
27
—
Leg .
L")
31
—
Clavicle
3
3
—
Humerus .
9
9
—
Fore-arm .
7
11
—
Lower jaw
1
1
—
Secondary
amputations
1
Total
82
K K 2
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Tempeuature Charts of Mr. Lister's Cases of Compound Fracture.
JXE
n.TTT
1
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Temperature Charts of Mr. Listers Cases of Compound Fracture (ty/i^ /(/«</;.
502 MESULTS OF ANTISEPTIC SURGERY.
Some writers have a fancy now-a-days to group tlie cases
according to age. The following are the facts in these 95
cases : —
0-9 years 10-19 20-29 30-39 40-49 50-59 60-69 70-79
12 cases 25 19 20 8 7 2 1
(In one case the age is not known.)
If we again subdivide these into accidental and intentional,
we find the following : —
Accidental.
0-9 years 10-19 20-29 30-39 40-49 50-59 60-69 70-79
4 10 (1 death) 7 (1 death) 9 2 3 2 0
(In one case the age is not known.)
Intentional.
0-9 years 10-19 20-29 30-39 40-49 50-59 60-69 70-79
S' 15 12 11 6 4 0 1
It is thus evident that the results are not due to absence
of old patients.
The result exactly confirms the anticipations expressed on
p. 461, that where the element of shock is excluded, and where
the surgeon has merely to keep out the causes of fermentation,
not to eradicate them, the mortality would fall and an element
of certainty be introduced into the results.
In order to get comparative statistics similar to those given
in Chapter XVII., I have looked through Mr. Spence's account
of his work from 1872 to 1878, given in the papers to which
reference has already been made (p. 378), and the following
seem to be the facts : —
I find mention of 16 primary amputations during this
period, and of these 7 died. In only 1 of these cases is it
stated that death occurred within forty-eight hours, and thus
we have to consider 15 primary amputations with 6 deaths.
Then I find 5 secondary amputations with two deaths, neither
within forty-eight hours. Also 1 secondary excision which re-
covered. And then only 2 cases of compound fracture treated
conservatively, both of which recovered. Whether these are
all the cases of compound fracture treated conservatively, I
MR. SPENCE'S COMPOUND FRACTURES. 503
cannot say, but as these 2 are mentioned, I presume that had
there been any more, they would also have been stated. Hence,
in Mr. Spence's list of cases treated during the greater part
of the period referred to, and in the same hospital as Mr.
Lister's cases, we find traces (for they are not grouped) of 23
compound fractiu-es w^hich lived for more than forty-eight
hours, and of these 8 died, some of the deaths being due to
infective disease. These facts are also interesting as showing
what a large proportion of compound fractures are amputated
primarily in the practice of a surgeon not treating his cases
aseptically, and also the large proportion of secondary opera-
tions. For of 23 compound fractures 15 were amputated
primarily (6 deaths), 5 were amputated and 1 excised second-
arily, and only 2 were treated conservatively. And even if
Mr. Spence has not published all his cases of compound frac-
tures the facts remain equally striking, for, with a much
smaller number of patients than Mr. Lister and with less
hospital accommodation, Mr. Spence has performed a larger
number of primary and secondary operations.
But from these papers I glean the following facts which
are free from any objection. During this time (1872-78), 6
compound fractm-es seem to have been made on healthy bones
by Mr. Spence, and of these 2 died. One case, however, died
in 36 hours, and therefore, following our rule, we have 5
intentional compound fractures of healthy bones with 1 death.
These were, 1 excision of the head of the humerus in a case
of unreduced dislocation — death in thirty hours ; 1 excision of
the knee for bad anchylosis ; 1 operation for badly united
fracture of the femur ; and 3 excisions of the elbow for anchy-
losis— 1 of these cases subsequently underwent amputation and
died, apparently of septicaemia.
Before leaving Mr. Lister's results, I may refer to some
operations on bones which have the same dangers as com-
pound fractures, though the bone is not fractured across.
Tlius the removal of exostoses is a serious matter. Mr. '
Tiister has operated for exostoses thirteen times (from the end
of 1871 till Octol)er 1880), four times on the femur, and twice
on the tilna, without any ])ad result.
Ill chi-oiiic osteitis not yielding to treatment, Mr. Lister
504 RESULTS OF ANTISEPTIC SURGERY.
cuts down, exposes the bone for a considerable extent, and
then digs a long deep trough in it with the gouge and hammer.
This treatment at once relieves the pain, and generally cures
the disease. Mr. Lister has performed 10 such operations
(from the end of 1871 to October 1880), without the slightest
bad result in any instance.
And then there are a number of operations in which, as in
the removal of tumours, portions of bone have been cut away
without any bad result.
By including all these operations together the number of cases
could be very much increased without the addition of any bad
result. I have preferred, however, to adhere rigidly to the
cases of compound fracture, meaning by that not subcutaneous
division of the bone, but a large wound open and communicating
freely with the bone, generally by means of a drainage-tube.
I shall now consider the results obtained by other surgeons,
and I shall take first, as being the most remarkable results as yet
published, the statements made by Dr. MacEwen in the ' Lancet '
for September 18, 1880. He there gives the result of all the
cases in which he has made compound fractiu-es aseptically.
He points out that these cases were really compound fractures,
and not in any sense could they be called subcutaneous opera-
tions. The wounds varied in length from | inch to 1^ inch,
and the edges of the wound were held aside so that the bone
was freely exposed, and purified air had free access to the
divided fragments. In this way he has operated on 330
.patients affected with various deformities. Of these 220 had
knock knee (367 limbs), 64 had bow legs (104 legs), 40 had
tibial curves &c. (80 legs), and 6 had osseous anchylosis of the
hip or knee The bones were either simply divided by the
chisel and hammer, or wedge-shaped portions were cut out.
Although he only operated on 330 patients, he produced com-
pound fractures on 557 limbs. And as he often produced 2
or more separate compound fractures on the same limb, it
came about that he had in all made and treated aseptically no
less than 835 compound fractures.
What were the local results ? Here we have to consider
835 compound fractures, and here Dr. MacEwen tells us that
only in 8 out of these 835 wounds did suppuration occur, even
MacEWEN'S compound fractures. 505
though union by first intention was impossible. In one case
there was no apparent cause for the suppuration ; in the other
7 cases some cause was present. In 3 instances irritation and
inflammation were set up by the pressure of the splint, &c. ;
in 3 cases there was bruising and laceration of the soft parts ;
and in 1 a piece of muscle was severely injured in adjusting
the bones. In each of these 8 cases the occiu'rence of suppur-
ation was preceded by elevation of temperature.
What was the result as regards the necessity for further
operation? Here we have to speak of ^51 limbs ; 557 cases in
which secondary amputation might have been necessary.
Secondary amputation was, however, only necessary in one
instance, although some of the limbs had as many as four or
five compound fractures. The operation in this case was neces-
sary because, owing to an accident, the bandages had become
displaced, and gangrene of the foot occurred. This patient
recovered perfectly.
What were the results as regards life ? Here we have to
consider 330 lives which might have been lost, and in con-
nection with this it is to be remembered that many of these
patients had multiple comj^ound fractures, in some instances as
many as 10. And yet of these 330 cases only 3 died, and not one
of these deaths was in any way due to the operation. MacEwen
describes these 3 cases in detail, and I may state that the
causes of death were diphtheria, tubercular meningitis, and
pneumonia contracted before the operation.
To sura up Dr. MacEwen's results, we find that of 330
patients only 3 died, in each case the fatal result being inde-
pendent of the disease : of 557 limbs affected with compound
fracture only 1 required secondary amputation or other opera-
tion, and this from a cause independent of the wound ; and
lastly, of 835 compound fractures, suppuration only occurred in
8 wounds, though primary union was impossible in all.
These results are the more striking when it is remembered
that many of the patients operated on were not in good
health, ' On several occasions,' says Dr. ]MacEwen, ' the patients
were so weak that there was considerable hesitation about
administering an anaesthetic. Many have been carried to the
wards by their friends, as they were unable to walk exce[)t by
506 RESULTS OF ANTISEPTIC SURGERY.
the aid of crutches, and that for a very short distance.' It is
indeed strange that such facts are allowed to pass entirely un-
noticed, and that in spite of them surgeons continue to assert
that equally good results may be obtained by cleanliness, good
ventilation, &c. These injuries will be generally acknowledged
to be grave ones, and there is no record whatever of anything like
similar results from other than aseptic methods of treatment.
In reference to the statistical value of such cases, Mr. Holmes
justly remarks : ' Of all wounds, perhaps those of compound
fractures of the leg are the best adapted for studying the effect
of different ways of dressing. Amputations and other major
operations depend so much more for their success on the health
of the patient and the previous course of the disease, that it is
hardly possible to draw^ from their results any absolute con-
clusions as to the effect of the system of dressing. This
objection applies, of course, to compound fractures to some
extent (as indeed it does to every surgical affection) ; but much
less than to amputations, especially when the severer accidents
which call for immediate amputation, or which prove fatal from
other injuries, are left out of account.'
Professor Volkmann has published a detailed account of all
the compound fractures treated by him conservatively since he
introduced the aseptic method. These are 73 in number (75
fractures), and of these 73 patients not one died.^ In one or
two cases of injury to joints, primary resection was practised.
These, of course, still remained compound fractures, and are
very properly included here. The following is Volkmann's
list:
Seconrlai-y Rocoiifliry Death
resection anii)utation
Part injured
Femur
No. of
cases
1
No. treated
conserva-
tively
1
Patella
3
3
Leg .
43
36
Humerus .
8
8
Fore-arm ,
20
14
75 G2 n 8 0
' In hi.s address at the recent meeting of the International Medical Con-
gress in London, Volkmann said: 'When I adopted the anti.septic treatment of
wounds my last 12 patients, with compound fracture of the leg, had all died
of py;emia or scptici\3mia. From that time up to tlic ])rcscnt day I have
VOLKMAAWS COMPOUND FRACTURES. 507
Now, in considering these facts we have first to notice, that
no less than 48 patients were injured by direct violence, and
that in 20 cases the bones were extensively shattered. A
number of the cases were machine accidents, and Volkmann
says with regard to these, that it was at first a very difficult
matter to decide whether any attempt ought to be made to save
these limbs. In 19 of the cases joints were involved in the
injuries : of these 5 were resected and 3 amputated secondarily,
while 1 1 were treated conservatively to the end. In 2 cases
primary resection of the joint was performed, once at the
shoulder -joint and once at the elbow-joint.
The following are the ages at which these accidents oc-
ciured :
61-70
1-10
11-20
21-80
31-40
41-50
51-60
5
13
14
17
10
9
With regard to the cases of secondary amputation and
resection, Volkmann expressly states that they chiefly occurred
soon after the treatment was first introduced, and that with
increasing experience of the aseptic method these cases have
become more and more infrequent ; and he states that 3 cases
of secondary amputation would have been unnecessary if the
injuries had been, in the first instance, properly diagnosed and
treated. In speaking of the results of his cases he rightly
divides them into two sets, the first being those which occurred
during the first year, while they were learning the method ; and
the second, those treated during the remainder of the period
(three years or more) after they had learned the method. In
the first set they had always suppuration and sometimes gan-
grene of portions of the skin ; here they injected a strong
solution of chloride of zinc at first, and afterwards they washed
out the wound daily with carbolic lotion. When they found
that chloride of zinc ought not to be used, and that it was
unnecessary and hurtful to wash out the wound, they got very
different results. Then they found, and this was the case in
treated, one after anotlier, 135 compound fnictures. and not a single patient
has succumbed to either of those accidental wound diseases ; 133 were cured,
two died, one of fat embolism of the lungs during the first few hours, and
one, a drunkard, of delirium tremens.' Luncef, August 13, 1881.
503 RESULTS OF AXTISEPTIC SURGERY.
about the last 60 cases, that the fracture and wound behaved
as if they were subcutaneous, there was no suppuration nor
gangrene of the tissues, but, on the contrary, rapid heahng. As
a rule, also, necrosis did not occur, though in one or two cases
small detached fragments, which had been left at first, were
picked out of the wound afterwards. Volkmann describes the
course of the cases as follows : ' Grleich von Anfang an tritt
keine ortliche Reaction, keine Jauchung, kein Wund-reinigungs-
stadium auf ; das Markgewebe verjaucht nicht in der Umgebung
der Bruchspalte ; die geofFnete Markhohle und das blossgelegte
spongiose Grewebe werden sofort wieder durch Blutcoagula
verdeckt und abgeschlossen, die so lange liegen bleiben, bis sie
durch organisirte Grewebswucherungen ersetzt sind. Es ent-
stehen keine fissuralen (Bruchspalten-) Eiterungen, keine
inter-muscularen, subperiostealen und parossalen Phlegmonen,
keine Eitersenkungen und Eiter-retentionen, keine grosseren
Necrosen. Die antiseptische Methode gestattet die Heilung der
complicirten Fracturen gewissermassen unter dem feuchten
Schorf.' In only three cases did Volkmann fail to eradicate
the causes of fermentation.
Max Schede has also treated a number of compound frac-
tures aseptically. There were 37 cases admitted soon after the
infliction of the injuries, and only 1 did badly, and that case is
said to have suffered in the first few days from fatty embolism
and delirium tremens. No patient died. In 4 cases intermediate
amputation was necessary, thrice on account of gangrene due
to the direct violence of the injury, and once on account of
gangrene in the case just alluded to, where the patient moved
the limb violently and tore the posterior tibial artery, the
anterior tibial having been destroyed by the injury. All these
cases were the result of direct violence.
Taken along with Volkmann's 73 cases we have a total of
110 cases treated, in the first instance conservatively, without
a death. Of these, 12 required secondary amputation and 6
secondary excision, leaving 93 which recovered without fmlher
interference.
Max Schede adds the following interesting facts : — Seven
cases came under treatment between the second and the
sixteenth day after the injury ; these cannot of course be in-
VOLKM ANN'S COMPOUND FRACTURES. 509
eluded in the same category as those which came under treat-
ment within a few hours after the accident. Of these, 2 died —
1 admitted on the ninth day with tetanus and 1 admitted on
the sixteenth day with extensive suppuration ; 1 underwent
secondary amputation, and 4 were treated conservatively. As
I have previously pointed out, these cases illustrate the result
of treatment by antiseptics, because it is hardly possible to
render such a wound aseptic so long after the injury.
Before leaving Volkmann's results I shall refer to the com-
pound fractures made by himself. He has produced 71 com-
pound fractures on 59 patients. One of these cases died.
This occurred in the case of a bleeder who died of anaemia
about twenty-four hours after the operation — a case of excision
of the knee for anchylosis. Leaving out of consideration, then,
according to Mr. Holmes' rule, this case which died within
forty-eight hours, we have 58 patients on whom compound
fractures were produced without any fatal result. After the
70 compound fractmres which we have to consider, secondary
amputation was onl}^ necessary twice ; in 1 case a central
enchondroma in the tibia was found to be the cause of the
deformity, and the limb was therefore amputated ; in the other
case* there was very severe genu valgum in consequence of
arthritis deformans, but the exact reason for amputation is not
given. As to the bones affected, we have mention of 16 com-
pound fractures produced on the femur and 45 on the bones
of the leg. The other operations were for ununited or badly
united fractures, but the bones affected are not mentioned.
In comparison with these results Volkmann says, that the
journals of the surgical wards at Halle for former years contain
notes of 1 1 compound fractures of the thigh, of which 6 died,
and of 64 compound fractures of the leg, of which 26 died.
The proportion of cases which required secondary amputation
is not mentioned, but it is stated that many of the injuries
were very simple and the result of indirect violence.
During the year 1878-79 Bardenheuer, operating aseptically,
made 28 compound fractures on healthy bones without bad
result. He also performed 53 resections — 15 of the hip and
12 of the knee-joints — without a death.
MacCormac gives the results of the aseptic practice in
610 BESULTS OF ANTISEPTIC SURGERY.
St. Thomas's Hospital. There were 16 cases of compound
fracture treated (2 of the femm-, 3 of the upper extremity, and
1 1 of the tibia) without a death, and in only one instance was
secondary amputation necessary. He contrasts these results
with those obtained in the former six years during which
5-i cases of compound fracture were not treated aseptically,
and of these 12 died (4 from pyaemia and 4 from erysipelas);
one case required secondary amputation on account of gangrene j
and in several there was suppuration or erysipelas and a pro-
tracted recovery.
MacCormac also referred to 45 compound fractm-es made
by the sm-geon (since the address the number has risen to 57),
without a death. Thirty of these involved the knee-joint, and
though the wound in the soft parts was comparatively small,
yet it was ' quite large enough in many instances to allow
serious inflammation and putrefactive changes to take place
in it.' In no single instance did any serious result follow.
If, now, we sum up the facts already obtained and, following
Mr. Holmes' suggestion, exclude all cases of primary amputa-
tion, and of death within forty-eight hours after the injury, we
get the following remarkable results : —
/. Accidental Compound Fractures.
Adding together the results of Lister, Volkmann, Schede,
and MacCormac, we find that there were 164 cases of com-
pound fracture treated conservatively, in which an attempt was
made to purify the wound,' and of these 2 died, giving a
mortality, after accidental compound fractm-es, of 1*2 per cent.
But then one death certainly, and the other probably, was
independent of the injury. Among these are included a few
cases of compound fracture of the skull, but if w^e take limbs
alone, we find tliat 158 limbs were affected with compound
fracture, and among these secondary amputation was performed
in 15 cases and secondary excision in 5, leaving 138 limbs
which were cm-ed without operative interference.
' The numbers would be larger now, see note on p. 506.
GENERAL RESULTS IN COMPOUND FRACTURE. 511
//. Intentional Compound Fractures.
Adding together the results of Lister, Volkmann, MacEwen,
Bardenheuer and MacCormac, we have 530 patients affected
with 1,072 compound fractures, and of these only 3 died, giving
a mortality of '56 per cent., the causes of death being in each
case quite independent of the operation. Looking at the
results to the limbs, we find that 766 limbs had 1,068 compound
fractures, and that among these secondary amputation was
only necessary in 4 instances, or '51 per cent.
Adding together the cases of accidental and intentional
compound fractures, we iind that 694 patients ivere affected
with 1,239 compjound fractures treated aseptically, and of
these 5, or '72 per cent., died.
Or looking at the results as regards the limbs, we find that
924 limbs were affected luith 1,226 compound fractures, and
of these 902 recovered ivithout further operaiion, ivhile 19
required secondary amputation and 5 required secondary
excision.
In contrast with these results we have the following facts :
Volkmann and Franckel ^ found a record of 885 compound
fractiures of the leg in the reports of the German and English
hospitals, and, of these, 339, or 38*5 per cent., died. In the
above 694 cases treated aseptically, I have not been able to
give the exact numbers as regards the bones affected, but by
far the greatest number of bones injured were those of the
lower extremity, the injuries of the thigh and leg being about
equal in frequency, the femur being perhaps most often
affected. However, as the mortality after compound fracture
of the femur is greater under ordinary circumstances than the
mortality after compound fracture of the bones of the leg, the
comparative value of these statistics is increased.
Bauin in (ioUingen- lost ;i8 p. c. after compound fracture of the leg.
liillroth in Zurich - 38-7 „ ,, „
In P.reslau '' iOo „ „ „
In Halle '^ 406 „
In Bonn- 418 „ „ „
' \o\kmiinn'ti Sam iidtnif/, 117 118- ^ Ibid.
512 RESULTS OF ANTISEPTIC SURGERY.
Mr. Holmes' states that in St. George's Hospital, from
1865 till 1878 inclusive, after excluding cases of primary-
amputation and deaths within forty-eight hours, there were
treated by the ordinary methods 162 cases of compound frac-
ture of the leg, of which 40, or 24*6 per cent., died. A con-
siderable proportion of these cases was treated during a period
in which cleanliness, good ventilation, &c., were greatly in
vogue, and by surgeons who were much impressed with their
necessity. Among these 40 deaths were 21 from pyaemia
alone, and several of the remaining deaths were due to other
sejitic diseases.
I have previously, at p. 510, given the results in St. Thomas's
Hospital, the mortality there being 22*2 per cent.
These records correspond with the expressed views of sur-
geons of all ages as to the dangers of compound fractures pro-
duced accidentally or of operations in which compound fractures
are made On the other hand we have also the generally
acknowledged fact that subcutaneous osteotomies are practi-
cally free from danger, and the subcutaneous method is, as we
have previously seen, a form of aseptic treatment. The fore-
going facts show that it is not necessary to have recourse to
subcutaneous operations to ensure safety, but that the Listerian
method is equally, if not more efficacious, while the free access
to the bone is in many cases a great advantage, indeed in some
an absolute necessity.
I must now again refer to Carl Eeyher's results in the
Russo-Turkish war (see p. 401, et seq.) During this war he
treated 22 cases of compound fracture of the extremities
aseptically (by ' primary antiseptics,' as he terms it), and of these
4 or 18 p.c. died, secondary amputation being only necessary
in one instance. The following list shows the cases and the
results : —
Healed with
retention of
limb
4
2
12
Part injured
No. of cases
Died
Secondary
amputation
Humerus .
Fore-arm ,
Thigh
Leg .
4
3
3
12
1
3
1
Total
•
22
*0r 81-8p. c.
4
1
' St. 1
Gvorgi;
:'« HosjAtal Reports,
vol. ix.
GUNSHOT WOUNDS OF BONE. 513
During the same time he had 62 fractures of the long bones
treated with antiseptics or, as he calls it, with ' secondary anti-
septics,' and of these 23, or 35*3 p.c, died. The following is the
table :
■r. X • • 3 ewnnHnvv Ut'alud with
Part injured No. of cases Died amm°"itiin retention of
^ ' limb
Humerus ... 12 5 3 5
Fore-arm ... 3 — — 3
Thigh
No. of cases
Died
Secondary
amputation
12
3
•35
5
3
13
5
22
5
2
62
23
10
"Or 69-6
p. c.
12
Leg .... 22 5 2 17
Total . 62 23 10 37*
He also refers to 27 similar fractures not treated antisepti-
cally at all, but he gives no details of them, and only states
that up to the time of writing 8 had died of pyjemia.
The following are the fatal cases where aseptic treatment
was attempted : —
One compound fracture of the thigh died of fatty embolism • it
is not mentioned how long after the injury the patient died : in
this case the femur was completely shattered throughout its whole
extent, the wound of entrance being near the pubis. One compound
fracture of the thigh died from exhaustion, the residt of profuse
suppuration. One compound fracture of the thigh died from septic
suppuration. One compound fracture of the forearm — a shell injury
— -died of pyaemia.
With regard to these cases I need merely point out the
extreme difficulty of thoroughly disinfecting the wound and of
removing all portions of clothing from the wound. Reyher
refers to this i)oint, and it seems that in 3 of the 4 fatal cases
in which the aseptic method was tried, disinfection was not
successful. This is of course only what might be expected.
There is nothing m;igical about the injection of an antiseptic
into wounds, and unless the fluid reaches all the recesses of the
wound, and destroys all the causes of fermentation which have
been introduced into it, the wound cannot be expected to follow
an aseptic course ; it is not an aseptic l)ut a septic wound, and
the consequences of such a wound will be those of a septic not
of an aseptic one.
L L
514 RESULTS OF ANTISEPTIC SURGERY.
In considering the results of other forms of antiseptic
treatment, the only detailed account to which I can refer is
Kronlein's report of the results of the open method in Ziirich
(see p. 410). Kp'inlein states that between 1860 and 1867,
160 cases of compound fracture were treated, and of these 67
died ; 86 of them being treated conservatively with 21 deaths.
Between 1867 and 1871, 102 compound fractures were treated,
of which 27 died ; Q5 of these being treated conservatively with
14 deaths.
Though Kronlein tells us the number of cases amputated,
and the number treated conservatively to the end, he does not
tell us the number of primary and secondary amputations.
Now, of course, in considering the results of compound fractures,
we must divide them into those amputated primarily, and those
in which conservative treatment was tried ; the latter group
being subdivided into those which required secondary amplita-
tion and those which were treated conservatively to the end. Of
course the cases treated conservatively to the end are the most
favourable class, because they did not require secondary opera-
tion. But in judging of the success of consei'vative treatment,
it is necessary to know in what proportion of cases that treat-
ment failed and secondary operation was required. Now it is
only of the former — the successful cases — that Kronlein gives
us infonnation. With the view of getting a coiTect impression
on this point, I have gone over his statements, and the follow-
ing are the facts, so far as I have been able to gather them.
Of the 160 cases treated between 1860-67, 38 were ampu-
tated })rimarily, with 19 deaths ; 21 were amputated secon-
darily with 17 deaths ; and 15 were amputated, but whether
primarily or secondarily, I have not been able to ascertain ; of
these 9 died. 86 were treated to the end conservatively with
22 deaths. Now according to our I'ule the primary cases are
omitted. As to the 15 amputations with 9 deaths, I don't
know what they are, and therefore we shall put them in a
group by themselves. This leaves us with 107 cases in wliicli
we are certain that conservative treatment was attempted, and
of these 39, or 30*4 per cent., died. The result then, so far as
we know it, is —
OPEN TREATMENT OF COMPOUND FRACTURES. 515
No. of cases
Death;
107
39
(certain)
Secondary
amputation
21
(certain)
Recovered without
mutilation
64
(or 59-8 p. c.)
Looking at the results of the open method from 1867 to
1871, we find that 102 cases in all were admitted, and of these
27 died. Of these 19 were amputated primarily with 5 deaths ;
9 were amputated secondarily with 4 deaths ; 9 were amputated,
but whether primarily or secondarily I do not know, with 4
deaths; 65 were treated conservatively to the end with 14
deaths. Treating these cases like the former, we may say that
74 cases were certainly treated conservatively, and of these 18,
or 24'3 per cent., died. Thus —
No. of cases Deaths
74 IS
(certain) (certain) (or OS'D p. c.)
It is to be remembered in both cases that some of the
doubtful amputations were probably secondary, so that these
results are the most favourable. I may give further details of
the cases which we know about accordinsf to the limbs affected.
Secondary
Recovered with
amputatlou
mutilation
9
51
Total
Cases treated Conservatively.
(1860-67.)
art affected
No.
, of cases
Percentage of
cases treated
conservatively
Deaths
Secondary
amputations
Recovered
without
mutilation
Femur .
8
61-5
3
1
.5
Leg .
77
81
26
15
49
Humerus
9
47-3
4
2
4
Fore-arm
v^
39-3
6
3
6
107
66-8
39
21
64
Cases treated Cunservativel//.
(Open Method 1867-71.)
Part affected
No.
of cases
Percentafrc of
cases treated
conservatively
Deaths
Se(
ami
.'ondary
)utation
Recovered
without
nuitilation
Femur
12
70-5
3
1
9
Leg .
38
84-4
12
7
22
Humerus .
14
51-3
2
1
11
Fore-arm .
10
62r)
1
—
9
Total .
71
69- 1
I, L 2
IS
9
51
ol6 RESULTS OF ANTISEPTIC SURGERY.
It will thus be seen that some improvement followed the
introduction of the open method, but this in no way corresponds
to that effected by the aseptic method.
The causes of death are not given, but of the 39 deaths of
the first period, at least 27 were from pyaemia and septicaemia
(14 of the cases treated to the end conservatively and 13 of
the secondary amputations). Of the 18 deaths of the second
period at least 8 were from pyaemia and septicaemia (5 of the
cases treated conservatively and 3 of those amputated secon-
darily). As I have said, this is the most favourable statement
possible, and it does not include those which died of other septic
diseases.
I do not find any facts of statistical value, with regard to
the results with other forms of antiseptic treatment, but the
good results of irrigation and the water bath and of crust forma-
tion are well known, and have already been alluded to in the
history of the subject. The whole tendency of the facts
published in recent times is, however, to show that success
increases according as the method adopted fulfils more and
more the requirements of the aseptic principle; and the same
is evident if we look at the history of the subject and see the
successes obtained by the use of balsams, of crust formation,
of irrigation and the water bath, and of subcutaneous surgery.
SPINAL ABSCESSES. 517
CHAPTER XX.
RESULTS OF ANTISEPTIC SURGERY — {continued).
Abscesses connected with disease of the vertebrse. Best situation for opening
psoas abscesses : best time for opening them : after-treatment and after-
progress. Table of Mr. Lister's results : general summary and remarks on
these cases. Comparative statistics are wanting. Sir James Paget's
views.
Before discussing these results, I think that it will be most
convenient to consider the last group of cases to which I intend
to refer, viz. cases of abscesses connected with disease of the
vertebra?. The cases which I give here were treated by ]Mr.
Lister between the end of 1871 and 1879 ; and I will mention
all the cases which occurred dm-ing that period. I have been
careful to take oidy those abscesses which were unmistakably
connected with disease of the vertebrae, as indicated by curva-
tm'e, by the history of the case and the symptoms present, and,
in several instances, by the presence of pieces of bone in the
pus. Of course this list, like the others, does not represent all
the cases which 'Mr. Lister has ever treated asejitically, for he
had several cases under his care before this period, and both
before and during it, he has treated a number of similar ab-
scesses in private practice. Here, as in other instances, his
results have been better in private practice than in hospital,
because the cases were attended to either by himself or by
skilled assistants, while in hospital it was often nece.-;sary to
leave the changing of the dressings to students.
In the treatment of these abscesses the general principles
of aseptic surgery are carried out in the manner before de-
scribed, and I need not recapitulate the point:^ here. I must,
however, say a few words as to the best situation for opening
psoas abscesses. An abscess which has passed into the thigh,
518 RESULTS OF ANTISEPTIC SURGERY.
and which is pointing in the neighbourhood of the lesser
trochanter, is usually, under the ordinary modes of treatment,
opened at its most prominent situation at the upper and
inner part of the thigh. Now if the aseptic method is adopted,
it is quite evident that an incision in that situation leaves very
little space, only two or three inches, for the overlapping of the
dressings, while the edge of the dressing, being near the anus
and genito-urinary organs, is very liable to get soiled with the
excretions. Case No. 1 is an example of this, and hence it is
well, if possible, to avoid this risk ; indeed, these abscesses are
now never opened in that situation. Almost all the psoas
abscesses have up till the present time been opened above
Poupart's ligament, and the results have been very satisfactory.
An incision is made near the anterior superior spine of the
ilium, much in the line for tying the external iliac artery, and
the muscles are carefully divided as in that operation. When
the transversalis fascia is reached, the pus can generally be
made to bulge beneath it, and then a pair of dressing forceps
are pushed into the abscess cavity, the opening dilated, all the
pus squeezed out, and a large-sized drainage-tube introduced.
Though this opening is not dependent, yet, if the tube be large
enough, the drainage is perfectly satisfactory, and there is no
accumulation of discharge. The cavity in the thigh drains
upwards into the iliac fossa and closes entirely in a few days.
The after-treatment has been already described ; after a time,
in these cases, a drainage-tube without holes except at its
upper extremity, is most useful.
Mr. Chiene advocates the opening of these abscesses above
Hie crest of the ilium behind by means of an incision at the
outer border of the quadratus lumborum. The advantages
which he claims for this method are the following : the orifice
is dependent, and thus the drainage is most satisfactory ; the
incision is made into the upper part of the aljscess, and thus
the whole of the cavity in the iliac fossa closes rapidly by
adhesion of the gr^n^ilations, so that, after a few days, there is
only a short sinus eading directly to the seat of disease. This
situation is an advantage, more especially in the after-j^rogress
of the case, when the sinus becomes too narrow to admit a
drainage-tube, for if a sinus is long and tortuous, the drainage
TREATMENT OF SPINAL ABSCESSES. 519
of the discharge from the seat of disease is of course more
likely to be imperfect than if the sinus is short and leads
directly to the diseased bone ; further, the orifice of the drainage-
tube is still more distant from sources of putrefaction in this
situation than when the incision is in front ; the dressing can
also be very securely applied and fixed.
These abscesses ought to be opened as soon as they are
detected. The spontaneous absorption of abscesses is a very
rare occurrence, and the treatment by repeated aspiration is very
apt to be unsatisfactory. The earlier the abscess is opened,
provided that it is done aseptically, the better, and this for two
chief reasons. In the first place the longer the pus is left,
the larger does the abscess cavity become ; and thus for the
first few hours after it is opened there will be, corresponding
to the extent of the abscess, a proportionate amount of serous
oozing, which, if great, will severely tax the efficiency of the
gauze dressing ; there will also of course be a larger cavity to
heal. In the second place the pus being pent up in a cavity,
tends, by tension and consequent nervous disturbance, to keep
up and even aggravate the chronic inflammation of the bony
tissue, and therefore, so long as the pus is there, the chronic
inflammation is kept up and the disease of the vertebrae pro-
gresses instead of improving. On the other hand, when the
pus is let out, and care is taken that causes of fermentation
are not admitted, a great source of disturbance is removed,
and an opportunity is afforded for the cessation of the disease.
For these reasons, therefore, the abscess ought to be opened as
soon as possible. I do not of course mean to advise the early
opening of these abscesses where the aseptic method is not to
be used, or where the surgeon has not had sufficient experience
of that method to be able to rely with considerable certainty
on excluding the causes of fermentation. But if the surgeon
considers that he can exclude these causes, then I believe that
the best thing for the patient is to open the abscess as soon
as possible.
The after-progress of these cases is exceedingly satisfactory.
For some hours after the abscess is opened, there is a profuse
discharge of bloody serum, due no doubt to the effect of the
diminution of pressure on the vessels in the granulation tissue
Gi'O RESULTS OF ANTISEPTIC SURGERY.
lining the abscess cavity. This discharge rapidly diminishes,
and in a few days beconaes very slight. After the original pus is
evacuated there is no more pus formation from the abscess cavity,
provided that the drainage is efficient and that the discharge
is kept aseptic. There may be a little suppuration from the
granulations surrounding the orifice of the drainage-tube, which
are irritated by the direct application of the carbolic acid, but
there is no suppuration from the deeper parts. As a conse-
quence of the slight amount of discharge the dressings are not
often changed, and generally, in a few weeks after the abscess
has been opened, the case is only dressed once a week, and
then not because discharge has reached the edge of the dress-
ing, but, for the reasons given on p. 93, because it is considered
that the dressing is no longer sufficiently antiseptic.^ A sinus
often remains for a long time, sometimes for months, and the
weekly dressings must be continued till it finally closes, the
greatest care in carrying out the minutest aseptic precautions
being required till healing is complete. Never be tempted, how-
ever slight the discharge, or however apparently superficial the
sore, to give up the aseptic method or to substitute boracic for
carbolic dressings. During the whole treatment of the case the
patient must be kept absolutely recumbent, whether lying on
his back or on his side is of little consequence, and must never
be allowed to raise his shoulders for any reason whatever.
Grenerally, after the sinus has healed, it is well to maintain the
perfectly recumbent position for at least six weeks longer, so
as to ensure that the bones are sound before the weight of the
body is allowed to tell on them. The maintenance of absolute
rest is essential for success.
The constitutional state of the patient rapidly improves
after the abscess is opened. If hectic fever is present before-
hand, it generally rapidly subsides (see T. Chart LIV), and the
temperature becomes normal, and remains so throughout ; and if
the temperature is normal before the abscess is opened it does
not rise nor assume a hectic type, as is so common when the
' I may just recall the fact alluded to on p. 89, that when dressings are left
on for a week, there sometimes occurs a little irritation beneath them, and that,
therefore, it is well to rub a little of the salicylic cream on the skin around
the wound before applying the dressing.
ASEPTIC COURSE OF ABSCESSES. 521
discharge is allowed to putrefy. The general condition of the
patient corresponds entirely to this state of the temperature : if
he has been weak and sutfering before, he rapidly regains
strength, loses his pain, and puts on flesh ; his appetite returns,
and he soon feels in a state of perfect health. The reason for
this is evident ; the patient is not exhausted by the daily loss
of a large quantity of discharge, while he is relieved from the
presence of the abscess. Cod-liver oil and iron are, of course,
given throughout, but stimulants are rarely necessary, at least
after the first week or two. Although these cases remain so
well, and although the discharge is soon practically nil, yet
they are as a rule very tedious, and it is well not to reckon on
cure in less than six or eight months ; some cases indeed last
much longer. It is expedient, therefore^ to warn the patient's
friends of this before the abscess is opened, for otherwise they
may get discom-aged and take the patient away ; and if aseptic
treatment is not continued to the end, the chances of recovery
are almost as slight as if it had never been employed.
A number of examples of the ' aseptic course ' of these
abscesses just described will be found in the following table, so
that I need not detail a case here.
522
RESULTS OF ANTISEPTIC SURGERY.
Psoas and
Xanie ami Ajre
Jane T., 38
Donald T., 24
Thomas G., T)
William L., 4;")
Thoiiins M., 02
Peter L., 3.'
Date of Operation and
Discharge ; with Result
Op., Dec. 21, 1871.
Dis., Jan. 31, 1872.
Result, putrelied.
Op., Feb. 10, 187
/>/«., Felj. 1.S73.
Rfxiilt, cured.
Op.. April 2, 1872.
liexitlt, unknown, pro-
bablv cured.
Op., April 1872.
ni.f, April 3, 187;
litsiilf, cured.
Op., Julv 4, 1872.
IJis., April 2, 1873.
/i fsiih, died of an in-
dependent cause.
0/>, Se|)t. 1872.
/>/.s., Oct. 21, 1873.
Result, cured.
Disease.
Larjije p.soas abscess forming a buljjing tu-
mour in the thigh and extending high up
in the abdomen. First noticed six months
previously, pain in back, &c.
Lumbar abscess. Patient hurt his back two-
and-half years ago, pain in back, &c.
Pso.is abscess in connection with advanced
spinal disease. A lumbar abscess appeared
later.
Lumbar abscess. Curvature of spine, &c.
Lumbar abscess. Patient first noticed a
swelling three months previous to admis-
sion. There was no curvature but great
jiain on pressure over the spine in the hnn-
bar region.
Psoas abscess with marked curv;iture of the
spine about the lower dorsal region. Ab.scess
pointing in the thigh. Disease began
nine years previously'. Suffered great ])ain
and had been getting weaker and thinner.
MR. LISTER'S SPINAL ABSCESSES.
Lumbar Abscesses.
Abscess opened in thi^h and 40 oz.
pus evacuated. Drainaije-tvibe
serted.
Opened, 10 oz. of pns evacnated. Drain-
age-tube inserted.
Opened, drainage-tube inserted. (The
lumbar abscess was opened in Octo-
ber).
Abscess opened. Drainage-tube in-
serted.
Oponed. Drainage-tnTie inserted.
0|)cned. Drainage-tulje inserted. Tlio
material evacuated was verv thick.
On December 26, it. was found that the menstrual
flow had soaked the dressings and the dis-
charge had a disagreeable odour. On Decem-
ber 28, a large piece of bone came away. As
the abscess was undoubtedly putnd, and as the
patient was very anxious to go home, she was
allowed to do so. At that time there was pro-
fuse discharge and the patient was getting
weaker.
The discharge rapidly decreased in amount, be-
ing in tlie main serous though occasionally
somewhat purulent. The abscess had com-
pletely healed on October 24, but on November
11 the cicatrix gave way and a sinus was re-
established. This he.iled jK^rmanently about
the end of January.
After opening the first abscess the discharge was
considerable and purulent, but there was no
smell. Many fr.agments o( bone came away
during the course of the summer, and in Octo-
ber a lumbar abscess was found and opened.
The case is not completed in the note liooks,
the last note having been taken on April 20,
1873, to the etlect that there was very little
discharge, and that the general healtii was good.
1 should think that the case was in all proba-
bility cured.
Aseptic course. The wound was found healed on
August 11, but the scar again opened. Healed
again on October 13 ; again the scar gaA-e way.
Healed permanently on December 10. For
some time the patient could not do without a
spinal support, but in July 1877 he showed
himself, and was then perfectly well and strong
and able to do any kind of work.
On November 28, some cui-vature of the spine
was noticed. In February the dressings were
changed weekly, there being only a small
sinus, which at the end of March had almo.st
absolnteh' healed. At this time a small glan-
dular abscess formed in the neck and was
opened and dressed with boracic lint. On
Marcli 23, erysipelas attacked this wound and
quickly spread over the head and neck. The
patient got npidly weaker, and died on April
2. (This is really a case of cured lumbar
abscess dying of another cause before leaving
hospital.)
Aseptic course, tlie discharge being jiurely ser-
ous and very slight in (inantiiy. Healed in
September 1873.
524
BUSULTS OF ANTISEPTIC SURGERY.
Psoas and
No.
Name and Age
Date of Operation and
Discharge ; with Result
Disease
7
T. H., 9 . . .
Op., Feb, 8,1873.
7>/s., Mawh §, 1873.
Result, in process of
cure.
Three lumbar abscesses. Curvature in the
dorsal regiou. Patient weak and thin.
8
Helen T., 24 .
Op., May 7, 1873.
JHs., Dec. 22, ,,
Result, cured.
Psoas abscess, Avhich had passed into the
thigh. Patient began to feel weakness in
the back about six months previously.
She had noticed the swelling in her thigh
for three months.
9
Donald R., 2G .
Op„ June 2, 1873.
JJis., Jan. 23, 1874.
Result, cured.
Psoas abscess pointing in the thigh. Curva-
ture in the lower lumbar region.
10
Jane R., 27 . .
Op., July 2, 1873.
JJis., Feb. 2, 1876.
Result, cured.
Patient was admitted in June 1873 on ac-
count of suppuration of the sheaths of the
flexor tendons of the hand following an in-
cision into a bursitis of these tendons not
performed aseptically. On July 2, a psoas
abscess was found in the right iliac fossa.
Had suffered from pain in her back for
about a year, and for some time from ab-
dominal tenderness.
11
Anne McK., 22
Op., Aus- 21, 1873.
JJis., Spring 1875.
Resu t, cured.
Lumbar abscess with well-marked curvature
of the lower dorsal vertebrai. A second
abscess formed later.
12
— W., 32 . .
Op., Sept. 2, 1873.
JJied, Feb. 3, 1874.
The cause of death
was phthisis.
Psoas abscess pointing in the thigh. Curva-
ture in the lumbar region ; great pain in
the back. Advanced phthisis.
13
Eliza M., 30 .
Op., Feb. 19, 1874.
JJis., Nov. 10, „
Jiesult, in process of
cure.
Dorsal abscess. Great tenderness on pres-
sure over the whole dorsal vertebrai and
curvature of the middle ones. Patient
ver}' weak and anaimic. The pain began
a year ago. Patient half-witted.
MR. LISTERS SPINAL ABSCESSES.
625
Lumbar Abscesses {continued).
Opened. Drainage-tubes inserted.
Opened. Drainage-tube inserted, 30 oz.
of pus were evacuated.
Opened above Poupart's ligament.
Drainage-tube inserted, 23 oz. of pus
evacuated.
Abscess opened above Poupart's liga-
ment, 20 oz. of pus containing pieces
of bone were evacuated. Drainage-
tube was inserted.
Opened, 10 oz. of pus evacuated.
Drainage-tube inserted.
Opened, "24 oz. of pus
Drainage-tube inserted.
evacuated.
Opened, 24 oz. of pus
Drainagc-tul)e inserted.
evacuated.
On Feb. 23, the two smaller abscesses had closed.
The drainage-tube was removed from the other,
and by March 8, the discharge was very slight.
The parents were very anxious to take the
child home, and they were allowed to do so
after having been instructed in the method of
dressing. The general health was at that time
improving.
Aseptic course. After .June 3, the case was
dressed every second A&y, and after July 6,
every three days. Healed about the beginning
of November.
Aseptic course. No more pus. Found healed on
October 10. Patient allowed to get up for the
first time on December 6.
The discharge rapidly diminished, and the case
was soon dressed only once a week. Aseptic
course, the discharge being purely serous. On
December 2, 1874, abscesses were found in con-
nection with the elbow-joint and opened, the
patient's health being then good and the psoas
abscess almost healed. When the patient left
hospital everything was sound. When heard
of in 1877, she was well and strong and had a
fairly movable elbow-joint.
Aseptic course. Quite healed on July 31, 1874.
On September 1.5, 1874, she was allowed to sit
up for the first time, but aftenvards felt great
pain in the dorsal vertebrae. She again sat up
on October 3, but again had pain. On October
22, a small abscess was opened at the side of
the former one. This healed during the spring
of 1875, and the patient was discharged cured.
(The exact dates of healing and discharge can-
not be ascertained.)
Till the middle of November the case went
on well, and the general health seemed to im-
prove, but from that time tlie lung disease
rapidly got worse and the jiaticnt gradually
became weaker. Diarrlioea set in in January.
During the last two or three weeks there was a
considerable increase in the amount of the dis-
charge, which became purulent.
The abscess went on as usual, the discharge
diminishing, and the i)atient's health improv-
ing when, on April 0, she tore off the dressings.
Ne.xt day there was a slight .smell, and the
wound was injected v.ith 1-20 carbolic lotion.
The discharge thereafter was odourless. No
notes are given from the end of April till
Novcml)er 10, when she is said to have been
' discharged in process of cure' (See T. Chart
LV.)
526
RESULTS OF ANTISEPTIC SURGERY.
Psoas and
14
15
IG
18
10
21
Name and Age
Margaret M., 7
Marfiaret S., 20
Susan J., 12
William M., 6
William L., 25
Tlionias M., 15
Mary C, 4
Margaret W., 24
Date of Operation and
D ischarge ; with Result
0;^., July 1874.
IJis., Jan. 1875.
Result, cured.
Op., Aug. 3, 1874.
TJis., Sept. 2, 1875.
Result, cured.
0/j.. Aug. 17, 1874.
Dis., April 17, 1875.
Result, putretieii.
Op., Sept. 14, 1874.
Dis., Nov. 7, 1876.
Result, cured.
Op., Jan. 10, 1875.
IJIs., June 10, „
Result, left hospital
before healing was
complete.
Op., .July 4, 1875.
Result, cured.
Op., Nov. 18, 1875.
Dis., June 27, 187(5.
Result, putrefied.
Op., Nov. l(i, 1875.
7>/Vf/, March 17, 1877
Result, died of ex-
haustion.
Psoas abscess, angular curvature in the lum-
bar region. Began six months before ad-
mission.
Dorsal abscess. Angular curvature in the
dorsal region. Symptoms began eighteen
months before admission. Patient thin,
without appetite, and had cough and
ha:moptysis.
Psoas abscess,
gion.
Curvature in the lumbar re-
Psoas abscess, which had not yet passed into
the thigh. Curvature in the lower dorsal
region.
Psoas abscess,
gion.
Curvature in the lumbar re-
Lumbar abscess. Patient was admitted in
May with an abscess connected with a
carious rib.
Psoas abscess with disease of the vertebrw.
Psoas abscess pointing in the thigh. Acute
curvature in the lumbar region. The ab-
scess extended all round the thigh.
MH. LISTERS SPINAL ABSCESSES.
627
Lumbar Abscesses {continued).
Opened, 1-4 oz. of pus evacuated.
Pieces of bone in the pus. Drainaye-
tube inserted.
Opened, 5 oz. of pus
Drainatre-tube inserted.
evacuated.
Opened, 8 oz. of pus evacuated. No
dr;iinaire-tube was inserted.
Opened by a dissection as if to tie the
external iliac artery. Drainage-tube
inserted.
Opened like No. 17, lo oz. of pus eva-
cuated.
Opened. The spinous process of one of
tlie lumbar vertebr.t was felt to be
bare. l)rainjiLre-tube inserted.
O] enodlike Xo. 17, above l'"Upart's liga-
ment. Drainage-tube inserted.
0]>ened, .lO oz. of jais evacuated con-
taining pieces of bone.
Aseptic course. Healed November 20, 1874.
Allowed to sit up on January 9, 1875. Exact
date of discharge not given.
Asefitic course. Healed in August 187.5. Patient
rapidly picked up Hesh and regained her appe-
tite after the abscess was opened. When she
was di>charged she was stout and well.
On September 8, this wound had healed, but a
collection soon reformed, which, on evacuation,
was found to consist of clear yellow serum.
During the month of February the case seems
to have p)utrefied, and on March 22, aseptic
measures were stopped and wet boracic lint
applied. Sent home.
Aseptic course, but the patient was extremely
restless, and it was very difficult to prevent him
from sitting up. To this is possibly due the
long delaj' in healing. This abscess was found
healed on Septetnber 15, 1876. A second ab-
scess formed on the opposite side and was
opened during t)ctober 1875. This had healed
before the patient was discharged.
The wound was doing well, but the patient got
tired of hospital, and wouLl not t-tay longer.
The tube was therefore removed and he was
taught how to dress the wound asepticalh'.
When he left his urine was albuminous, but its
state on admission is not given.
This ciise seems to have followed an aseptic course ;
the ]>atient left the hospital healed and cured.
But the notes are abotninably taken, and tlure
is no note either of the date of healing or of the
date of dismissal.
This case did wel till the Christmas liolidays,
when putrefaction seems to have occurred.
After that time there was profuse jiurulent
discharge, tliough for the most ]iart odourless.
The child was getting thinner and weaker, and
the parents wished to take her home.
All through the ca.se there was great difticulty in
getting free drainage, and consequently there
was an unusual amount of discharge, the ca.se
rer|uiring dressing about every .second day.
Laticrh" tlie patient sulii-red stvere jiaiu in tiie
thigii, leg, and liacU, with constant vomiting.
On posl-niorlem exaiiiin.ition tlie lumbar verte-
bnvj were found to be completely disorganised,
cavities containing cheesy material being found
in the bodies, transver.se and spinous jirocesses
of the vertcbriu. The bodies of two vertebraj
were absent. Tlie liver, spleen, kidneys, and in-
testines were in a state of waxy degeneration.
For T. Chart ju^t before death, see No. LIU.
528
RESULTS OF ANTISEPTIC SURGERY.
Psoas and
Name and Age
Date of Operation and
Discharge ; with Result
Disease
22
23
EUea S., 32 .
John D., 18.
24
25
John D., 24
Eliza T., 19 ,
Helen E., 60
Op., Nov. 14, 1875.
JJis., Feb. 3, 187G.
Result, cured.
P/)., March 22, 1876.
Dis., March, 1878.
Result, cured.
Op., April 4, 1876.
Died, Oct. 2, „
The cause of death
was phthisis.
Op., Aug. 1, 1876.
])is., July 1880.
Result, cured.
Op., Nov. 16, 1876.
Dis., Sept. 4, 1877.
Result, cured.
Largo lumbar abscess,
spine.
Curvature of the
Psoas abscess pointing in the left groin. Cur-
vature of the spine. Patient had been ill
for a year. He was in an extremely weak
and emaciated state. At a later period an
abscess formed in the right thigh.
Psoas abscess. Curvature of the spine in the
lumbar region. Patient was very weak,
and had advanced phthisis.
Admitted with a psoas abscess on the left
side, which had not j'et reached the thigh.
Great tenderness and curvature of the
spine in the lumbar region. At a later
period a psoas abscess formed on the other
side and also a lumbar abscess.
Patient injured her back a year before ad-
mission. It had been very weak and pain-
ful ever since, and when admitted there was
a psoas abscess pointing in the thigh.
Patieut was very weak.
I
MR. LISTEES SPINAL ABSCESSES.
629
Lumbar Abscesses [conthiued).
Opened. Drainage-tube inserted.
Abscess opened above Poupart's liga-
ment. Drainaire-tube inserted.
Opened above Poupart's ligament.
Pieces of bone escajied with the pus.
Drainage-tube inserted.
Opened above Poupart's ligament, 20 oz
of pus evacuated. Drainage-tube in-
serted.
Abscess opened above Poupart's liga-
ment, 18^07. of pus evacuated. Drain-
age-tube inserted.
Aseptic course. Healed November 20, 1876.
(See T. Chart LVL;
The psoas abscess went on very well. A large
abscess formed in the othpr thigh, and was
opened on February 11. The patient was re-
moved to a private house in October 1877, and
placed under Dr. Bishop's care. Dr. Bishop
writes as follows in tlie British Medical Journal
for Januiry 31, 1880: 'John D., healed in
March 1878. Left Edinburgh in May. When
last heard of he was able to v/alk without sup-
port, and was feeling quite strong.' (For T.
Chart for some days after the second abscess
was opened, see No. LIV.)
The discharge seems to have remained aseptic,
though latterly it increased somewhat in
amount, necessitating a change of dressings
every two or three days. His cough got worse,
he became weaker, and died of phthisis.
Aseptic course, but the case was extremely tedi-
ous. A psoas abscess formed on the right side,
and was opened on January 16, 1878. In
March, after a gymnastic performanre in her
bed, she felt great pain in her back, and a lum-
bar abscess formed and was opened on April
17, 1878 ; bare bone was felt by the finger.
The case went on with almost no discharge, the
dressings being changed only once a week, till
August 1879, whf-n the first sinus healed. In
the beginning of October this opened up again.
On November 22 the right psoas ab.^cess was
found healed, and on D;'cember 27, the lumbar
abscess had healed. Although the original
sinus had not yet henled, the patient was al-
lowed to get up in Februar}' 1«80. This sinus
healed in June 1880, and the patient went
home in t!ie be,i:inning of July. During the
whole time the ])atietit had been in good health,
and her rosy cheeks (not hectic) and appear-
ance of perfect health rendered it difticult to
persuade any one that she was suffering from
disease of the spine with two psoas and one
lumbar abscess. (See T. Chart LVII. taken at
the time when the second abscess was opened.)
Asejjtic course. Healed July 5, 1877. Before
her discharge she was able to walk about.
(See T. Chart LVIII.)
M M
530
RESULTS OF ANTISEPriC SURGERY.
Psoas and
Name and Age
27
John R., 10
'28
Hugh McL., 6,
29
Michael C, 21.
30
John B„ 25
31
John D., 29
Date of Operation and
Discharge; with result
Op., Nov. 20, 187G.
Din., Aug. 5. 1877.
Result, cured.
Op., Jan. 29, 1877.
Dig., Aug. 1878.
Result, improving.
Op., Jan. 28, 1877.
Din., May 1878.
Result, cured.
Op., Fel). 11. 187
Vis., Feb. 1878.
Result, cured.
Op., Oct. 12, 1877.
Uis, Jan. 1878.
Result, died.
PsoaG abscess pointing
ease of the spiue.
in the thigh. Dis-
Psoas abscess on the left side pointing in the
thigh. Extensive disease of the vertebrae
and curvature of the lower dorsal and
upper lumbar vertebr». An ab.scess formed
on the other side at a later period.
Lumbar abscess on the right side. Pain in
the back. A second lumbar abscess
formed.
P.soas abscess which had not passed into the
thigh. Had been treated for spinal dis-
ease for eighteen months. Patient very
weak.
Psoas abscess which had passed into the
thigh. The curvature of the spine began
at the twelfth dorsal and the most promi-
nent part was at the second lumbar verte-
brse. Patient much emaciated and very
weak.
1
MR. LISTERS STIXAL ABSCESSES.
53 1
Lumbar Abscesses (contiuued).
Treatment
Oi)ened in the thipjh. A sound was then
passed under Poujiart's liiz;anient, the
point projected against the skin and
cut out. The lower wound was then
stitched. Drainage-tube inserted into
the upper.
Opened like No. 27. Very thick pus
containing pieces of bone was evacu-
ated.
C)pened. Drainage-tube inserted.
Absce.'ss opened above Poupart's liga-
ment. Drainage-tube inserted.
Opened, 8."( oz.of pus evacuated. Drain-
age-tube inserted.
Aseptic course, soundly healed June 1877. The
w ound in the thigh healed in a few daj's, but pus
reaccumulated there, and it was necessarj- to
open the sear. (The object of the procedure was
to obtain an opening above Poupart's ligament
as far away from the pubis as possible with-
out the difficulty of a special dissection. It
was hoped that the wound in the thigh would
heal by tirst intention, and that the part of the
abscess in the thigh would drain into the abdo-
men.) (See T. Chan LIX.)
For some time the case went on very well, but it
was a matter of extreme difficulty to keep on
the dressings owing to his deformity. An ab-
scess formed on the opposite side and was
opened in May 1877. Putrefaction occurred
during the summer. Of this patient Dr.
Bishop writes: 'His father removed him in
August 1878 to the West of Scotland. He
was then considerably improved, having youth
on his side to resist the septic influences ; and
when he was last heard of he was running
about.'
Aseptic course. The second abscess was opened
February 25, 1877. Dr. Bishop says, 'Michael
C. healed in March 1878. Left in May. In
July 1878 he was able to go to Peterhead to
the herring fishing. He returned to the fishing
in 1879.' (See T. Chart LX.)
Aseptic course. Dr. Bishop says : ' John B.,
hceiled in December 1877 ; left in FebruMry
quite strong and well. When last heard of, he
was employed as a colporteur.' (See T. Chart
LXI.)
The patient a|)i)arently suffered from carbolic
l)oisoning, and therefore the dressings weie
left on for a long time and were made very
small, and creosote and ultimately thymol were
substituted for carljolic acid. .\s the result
<if these changes, putrefaction occurred. The
discharge became foul and exceedingly jirofuse
and the patient l)ecanie rajiidly w(!akcr. As
he exjiressed a desire to go home, lie was
allowed to do so. He died about a mouth after
he got home.
ii M 2
532
RESULTS OF ANTISEPTIC SURGERY.
Psoas and
No.
32
Name and Age
Lucy S., 22 ,
33
34
35
Marv R..
Sarah P., 21
Catherine C, lo
36
37
Henry W., 24
Mary P, 25,
Date of Operatii n and
Discharge ; with Result
0;>., July 23, 1878.
Dis., June 1879.
Result, cured.
Op., Oat 11,1878.
Dis. MMy 17, 1879.
Result, cured.
0/j., May 5, 1879.
Dk., Ai)ril 1880.
Result, cured.
Op., Feb. 6, 1880.
])is., Sept. „
Result, cured.
0/j,, June 2n, 1879.
Dis., .luly ]«S().
Result, in proce.ss of
cure.
Op., Oct. 7, 1880.
Result, cured.
Large psoas abscess. Also a collection of
flui'l in tlie f^ltiteal rcijioji. Curvature of
the lower dorsal vertebrae.
Psoas abscess, ■which had not yet passed into
the thigh. Considerable angular curva-
ture of the lower dorsal and upper lumbar
vertehne.
Psoas abscess pointing in the thigh. Had
noticed pain over the second and third
lumbar vertebne for twelve months.
Curvature of the spine chiefly in the lumbar
region. Psoas abscess. Pain in back.
Patient was admitted with disease of the
elbow-joint. Had suffered from pain in
the back for some time. An abscess was
found in the left lumbar region.
Psoas abscess. Prominence of first lumbar
vertebra. Great pain and tenderness over
that part ; she could not be touched or
moved without crying out. General health
verv bad.
MR. LISTERS SPINAL ABSCESSES.
:33
Lumbar Abscesses {continued).
Treatment
An incision was made into the abscess
above the crest of the ilium, and six
])ints of clear fluid were evacuated.
The fluid in the buttock was evacu-
ated by the same incision. Wound
stitched up.
Opened like Xo. 17. Dniinage-tube in-
serted, 14 07.. of pus with pieces of
bone escaped.
Opened above the crest of the ilium
about its middle ; oO oz. of thin pus
e;caped. Drainage-tube inserted.
Opened like Xo. 17, 8 o/. of thick mor-
tar-like pus escaped containing? pieces
of bone. Drainage-tulje inserted.
Opened. Drainage-tube inserted.
Abscess opened and 24 oz. of pus con-
tHining a piece of l)one evacuated.
Drainage-tube inserted.
The fluid reaccumulated in the buttock, and in
the beginning of August, 17 oz. of serous fluid
were removed bj' the aspirator. There was
again reaccumulation, and 18 oz. were with-
drawn on August 22. On September 4, the old
cicatrix was opened and a drainage-tube in-
serted. The tube got blocked, and there were
reaccumulation and high temperature. (The
patient was also menstruating at the time.)
As soon as free exit was provided for the
fluid, the tem]ierature fell. The case then
followed a typical course and the wound healed
during April 1879. She went home quite
well and strong in the beginning of June.
When the fluid was let out on September 4, it
had a peculiar odour and contained numerous
bacilli. These, however, disappeared in a few
daj's, being apparently either dead already or
incapable of developini; in the serous discharge
from the wound. (See T. Chart LXII.)
Aseptic course. Wound healed on March 4,
1879. Patient was in excellent health through-
out the whole treatment. (See T. Chart
LXIII.)
Aseptic course. Healed completely on February
25, 1880. Patient improved in general condi-
tion from the day of the operation. (See T.
Chart LXIV.)
For some days this mortar-like stuff containing
fragments of bone could be pressed out. Bv
February 24, the discharge was serous and the
case thenceforward followed a typical aseptic
course. The elevation of temperature on Feli-
ruary 9, and the following days coincided with
the patient's first menstruation. Healed during
July 1880. (See T, Chart LXV.)
.Vseptic course. In the summer of 1880, as tliore
was no discharge, even though the sinus had not
healed, the patient was allowed to walk about.
When the hosjiital was closed in July 1880, the
sinus was still unhealed. He was sent lionie to
be treated asepticallv by his own doctor. (See
T. Chart LXVI.) "
Aseptic course. The pain in the back di-ap-
peared in a few days and tin; patient's health
rapidly improved. Found liealed on June 16,
1881. Patient tlien well and strong and quite
free from jiain or tenderness. (See T. Chart
LXVII.)
msmammimmmam^mM
■
ziv
TEMriHA'II (!K CHAHTS OF CASKS OK I'SOAS AND LUMBAR ABSCESS.
I
T.YTT
XXL
zjnrr
7, XIV
LXV
,Im rwEM EiMElM E ME MEM EM E M E M HM EM EM E
I ■■■■■■■■■■■■
■■■■■■■■■■■■
Bptap
Lxvr
L.\\7f
'J';;.\ii'EiiATrKi'; Chauts n\- ('asks op I'shas and Lr.viHAit Ausckss (^(■(intiiHird ).
636 RESULTS OF ANTISEPTIC SURGERY.
Another case was admitted during these years, a little child
with psoas abscess. This was opened aseptically, but the parents
insisted on removing the child 3 days after the oj)eration, for no
apparent reason. As of course such a case could not be of any
value in regard to the effects of treatment, I have not included
it in the list.
We have thus 37 cases of abscess connected with disease of
the spine treated by free incision and the insertion of a drainage-
tube under strict aseptic precautions. Of these 23, or 62*1 p. c,
were certainly cured. This figure does not however represent
all the cases which recovered, for several of the patients left
hospital continuing the aseptic method, and I see no reason why
these did not also recover. I would thus consider that 4 other
patients (Nos. 3, 7, 18, and 36) were probably also cured, giving a
total of 27 cures, or 72*9 per cent, of cures.
Of these 37 cases 4 died in hospital, and 1 is known to have
died soon after leaving hospital, giving 5 known deaths in 37
cases, or a mortality of 13*5 p. c. But it may be said : 'The
cases which putrefied and were discharged also died ; ' and no
doubt some of them did. Reckoning these cases therefore as
also cases in which a fatal result ultimately occurred, we should
have 9 deaths in 37 cases, or a mortality of 24*3 per cent. We
know however that this percentage is too high, for the boy
No. 28 was improving in general condition when he was last
heard of, and he very probably recovered, and the result in
No. 16 was by no means certainly fatal.
If we enquire into the causes of death we find, that some of
them must necessarily be present in a certain number of these
patients. Thus Nos. 12 and 24 died of phthisis, while No. 21
died of exhaustion, and on post-mortem examination there was
found most extensive disease of the spinal column, so extensive
and of such a nature that the chance of recovery under any
circumstances was exceedingly minute, if indeed it can be said
to have existed at all. No 5 died of a cause quite independent
of the lumbar abscess ; indeed this case ought to be reckoned
as one which was cured of the lumbar abscess, but which died
from another cause before leaving hospital. The case shows
very well the dangers of a septic as compared with those of an
aseptic wound ; for for months the patient had had an open
MR. LISTER'S SPIA'AL ABSCESSES. 637
wound treated aseptically without any bad result, but he did
not have a septic wound many days before it was attacked by
erysipelas, of which the patient died.
The cases in which putrefaction occurred show very well the
contrast between the course of cases where the aseptic method
has failed (in other words the course of septic cases), and of
those where the aseptic method has been successfully carried
out. If we look at the causes of failure we shall see that in
one or two cases there was good reason for it. Thus in No. 1
the abscess was opened at the upper and inner part of the thigh
quite close to sources of putrefaction. It was this case which
showed the danger of incisions in this situation, and led to the
much better plan of opening psoas abscesses in all cases above
Poupart's ligament. The immediate cause of putrefaction in
this instance was that the menstrual discharge soaked the
dressing and conveyed putrefaction to the wound before the
accident was detected. Here also it must be noted, that the
application of an elastic bandage along the margin of the
dressings had not yet been introduced, and hence the edge of
the dressing was not always in apposition with the skin. That
putrefaction occurred under these circumstances is not a matter
for surprise. No case will go wrong from this cause in future.
Then in No. 28 the dressings slipped owing to the extreme
deformity of the patient and the difficulty in retaining them
in position, but this will probably also be avoidable in the future
by careful management. In No. 31 we had the complication
of carbolic poisoning — a complication happily extremely rare —
and by the use of one or other of the powerful antiseptics now at
our disposal we may, I think, reckon that if a similar case should
occur again, there will be no necessity for such treatment as
would involve the risk of putrefaction of the abscess. Then
we have two cases in which no explanation is given (Nos. 1 6 and
20). These were likely due to the carelessness of the dressers ;
one (No. 20) occurred during the Christmas holidays, when most
of the dressers were away, and when those who were left had
generally more work than they could do without hurrying
over it. Altogether, I believe that in future the chances of
a case going wrong are very small, as indeed we already see
from the more regular progress of the last cases. For, if we
538 RESULTS OF ANTISEPTIC SUItGERY.
look at the results since 187/), we find that 73*3 per cent, of
the cases were certainly, and 80 per cent, probably, entirely
cured, as against 59 per cent, of certain, and 72*7 per cent, of
probable, cures in the preceding four years. But this does not
yet give a true idea of the present probabilities, for of the two
cases which proved fatal since 1875 one died of an unavoidable
cause — phthisis — while in one putrefaction occun-ed under
circumstances which would not now happen, viz. the absence of
a ftiirly trustworthy substitute for carbolic acid. The results of
the last few years, both in hospital and private practice, shew
that in a patient not affected with phthisis or other dangerous
malady a cure is in the highest degree probable. •
If we look at the cases which recovered, we see that what
I stated at p. 519 is true — that the effect of opening a large
abscess aseptically and keeping it freely open by means of a
drainage-tube is not a severe attack of fever, nor profuse
suppuration, nor hectic fever, but is the relief of the patient
from any hectic symptoms from which he was previously
suffering, and his rapid return to a normal state of health
without any suppuration from the abscess cavity. The change
wrought in these patients is very remarkable. Some have been
brought into hospital in a very feeble and emaciated condition,
apparently rapidly dying, and yet in a few days after the abscess
was opened they recovered their appetite, they rapidly put
on flesh, and soon gained an appearance of robust health. The
cases which were cured were not cured after a weakening con-
finement to bed, but, when they left their beds, they were in
' With reference to all the cases mentioned, I need hardly point out that
the results obtained during a number of j'ears in which a method is being
developed do not give the jiresent jyrobahilH.ies of success. The asep'ic
method is much more perfect at the present time than in 1872, and therefore
the failures in the earlier period reduce the average results. It is only by
failures that advance is made, and the failures in the earlier period have led
to improvements which avoid these errors in future. For a very simple
example of this look at Case 1 of the psoas abscesses, where the failure led to
the selection of a better position for making the incision. In the same way
other failures led to the wetting of the deepest layer of gauze, to the use of an
elastic bandao-e, &c., and it is only the results since these improvements which
shew the present state of matters and which now give those who employ this
method great confidence in it.
SPINAL ABSCESSES NOT TREATED ASEPTIC ALLY. 539
good health and strong, while when they were admitted they
were in some cases miserable, weak, emaciated creatm'es.
This success after opening spinal abscesses aseptically has
been obtained by several surgeons who have used the method
carefully, while, on the other hand, surgeons who have been
apparently successful with other wounds have failed in tliese.
This is the case in which perhaps of all others faulty manipula-
tion becomes evident. For in an ordinary wound, as we have
seen, the healthy tissues may destroy causes of fermentation
should they accidentally enter the wound, but in an abscess
cavity like this, such destruction will not occur, and therefore a
slight error which might not matter and might escape notice in
the case of a wound, will entirely upset the result here. These
cases are really tests as to whether a surgeon is thoroughly
versed in the details of the aseptic method ; and till a surgeon is
able to reckon on success in these instances, he ought not to
ventiu'e on operations of convenience, such as many operations
on joints, &c., in which failure is apt to be followed by grave
consequences, nor ought he to bring forward his own experience
as telling for or against the aseptic system.
When I come to look for comparative statistics on this
subject I find none. During the Edinburgh period I do not
find mention by Mr. Spence of a single case of this kind, nor do
] find reference to them by other statisticians. I have, however,
in the history of this subject referred at length to the views of
surgeons on the dangers of opening these abscesses, and we have
seen that when they were freely opened and kept open, death
was looked for in the vast majority of cases. The only methods
which yielded any sort of satisfactory results were the valvular
method and the method by aspiration.
At the meeting at St. Thomas's Hospital, to which reference
has been already made. Sir James Paget said, 'A few years ago
I believed that I had never seen a patient recover after the
opening of a lumbar or a psoas abscess with a free incision ; I
could not remember one who had not died before the opened
abscess had healed. Of late years I have known such abscesses
opened with complete impunity under antiseptic treatment ; and
there has seemed nothing but this treatment to account for ihe
difference of results.'
540 RESULTS OF ANTISEPTIC SURGERY.
CHAPTER XXI.
RESULTS OF ANTISEPTIC SURGERY — (concluded).
General consideration of the results. Results of the various methods in saving
life. Results in avoiding infective disease. Cleanliness : definition of the
term : Mr. Savory's definition and method : cleanliness has not abolished
infective disease even in healthy hospitals : cleanliness is a complex
method : infective diseases may appear even in the best hygienic condi-
tions. The source of infective disease. Conclusions as to the value of the
various methods in preventing infective disease. Deaths from prolonged
suppuration after Chronic abscesses, compound fractures, &c. Operations
on weak or diseased individuals are rendered possible by the aseptic method.
Operations otherwise unjustifiable, but nevertheless necessary for the
recovery of the patient, may be safely done by the aseptic method. The
patient may be made a more useful member of society : joint cases :
tenotomy, &c. : compound fracture: dangers of operations of convenience.
Local results of wounds treated aseptically : absence of pain, inflammation,
&c. : experiments of Yeo and Ferrier : organisation of blood-clot, catgut,
sloughs. &c. Histological details of the process : Tillmann's experiments.
Temperature in aseptic cases : contrast with septic cases. Local and con-
stitutional course of cases not treated aseptically. Objections to
aseptic surgery : carbolic acid poisoning : the surgeon is said to neglect
the constitutional state of the patient : expense : trouble : necessity for
the spray. Conclusion : great principle of wound treatment is Rest.
We are now in a position to consider the points referred to at
pages 365 and 366, and first as to the results of the various
methods in saving life.
In Chapter XVII. I have brought forward a mass of evidence
to show what are the results of the various methods in avoid-
ing infective disease, and I must now refer to this evidence
very shortly. We have seen that the aseptic method, when
efficiently carried out, has practically abolished infective dis-
eases, and that this result has been obtained whether the
hospital was one in which these diseases were only present in
small amount, as in Pklinburgh, or whether it was one in which,
from some cause or other, they were rife ; where the hospital
ASEPTIC METHOD PREVENTS INFECTIVE DISEASE. 541
was, as it is said, infected. We have also seen that none of the
other forms of antiseptic surgery give the same certainty as
regards the result, and that the absence of infective diseases
increases in direct proportion to the increase in asepticity of the
wounds. I have merely to recall the facts from Mr. Lister's
own practice, which show the difference in the results of aseptic
treatment and treatment by antiseptics carried on by the same
surgeon, in the same wards, during the same time, in cases
more or less severe. (I cannot say ' of equal severity,' because
the cases treated aseptically were, taken as a whole, much more
severe than those treated with antiseptics.) The proportion of
infective diseases was four times as great in cases treated with
antiseptics as in those treated aseptically. But it must further
be noted, that the two cases in which the aseptic method was
employed and which died of infective diseases, were both
cases in which, through error in the manipulations, an aseptic
result was not attained ^ ; they were, in fact, septic cases. And
so it may be truly stated that in no case in which the aseptic
method was efficiently carried out., i.e. ivhere fermentation and
micro-organisms were absent from the ivound, did the patients
suffer from blood-poisoning. In other words, the aseptic
method, luhen efficiently carried out, was, in Mr. Lister^s prac-
tice, effectual in entirely preventing infective diseases.
Similar evidence is furnished by Volkmann, Nussbaum, and
others to the effect that in the very few cases in which infective
diseases occurred, faulty manipulation could be shown, and this
is further proved by the facts that these cases occurred at the
commencement of the trial of aseptic treatment, while as yet
the surgeons were learning the method, and that since they
have become thoroughly versed in its use these diseases have
disappeared.'^
' That two cases in which the aseptic method was applied died of infective
disease does not prove that the keeping of a wound aseptic is not sufficient
to prevent those diseases, because in neither of these cases was tlie wound
kept aseptic, a failure due entirely, as has been previously abundantly shown,
to faulty manipulation.
2 It appears to be generally the opinion of those who have had much expe-
rience in aseptic treatment, that while pyiemia and septica;mia are readily
enough got rid of, greater caie is required to prevent the occurrence of ery-
sipelas. The following is the explanation which J would give of this fact.
542 RESULTS 01 ANTISEPTIC SURGERY.
The other methods of antiseptic surgery are powerful in
this respect chiefly in so far as they prevent or interfere with
the occurrence of fermentation in the discharges of wounds.
And hence it is that among the best means, not entirely aseptic,
for accomplishing the purpose aimed at, are treatment by irriga-
tion and the water-bath, or the very free use of suitable anti-
septics. The open method and free drainage are also useful,
though to a less extent.
It has been asserted by some writers, more especially by
Mr. Savory, that the good results following the use of aseptic
methods were due to cleanliness, and that equally good results
are obtainable by cleanliness, combined with good ventilation,
&c., as are got by the Listerian method. By the term cleanli-
ness, as ordinarily employed, is meant the cleansing of in-
struments and sponges, in some cases the use of new sponges
at each operation and of fresh instruments in the dressing of a
case, plenty of water to wash the wound with, the use of fresh
and clean dressings, and great care in the ventilation of the
wards. Combined with these is careful nursing, good surgery,
good hygienic conditions, &c. Mr. Savory, however, defines it
as 'the prevention or removal or destruction of all matter
which may prove poisonous,' and this definition corresponds to
some extent with the meaning of the term ' antiseptic surgery '
as employed in this work, though I have limited it to the
methods which inteifere ivith the ^production of these poisonous
substances, rather than to those which neutralise their effect
after they are formed ; and I have also defined more clearly
There seems to be little room for doubt that erysipelas is a disease due to the
growth of micrococci in the skin and subcutaneous tissue, more especially in
the lymph channels. Now, as we have seen, one form of micrococcus enters
aseptic wounds comparatively readily, more readily than other forms of
organisms. We have no absolute evidence, however, that it is only one
form of micrococcus which can get in in the manner described in Chapter XII.
and it is by no means improbable that the form which causes erysipelas
might enter with considerable facility. Where, therefore, a wound is guarded
altogether against organisms, erysipelas is avoided ; but where care is suffi-
ciently relaxed to let in micrococci, it is possible that the micrococcus of
erysipelas may also enter, though the causes of other infective diseases are
excluded. That they cannot enter so easily as the micrococci previously alluded
to is proved by the absence of erysipelas in the practice of those who use
this method most carefully.
MEANIXG OF THE TERM ' CLEANLINESS: 543
what the nature of the enemy is with which we have to contend.
The mode in which Mr. Savory proposes to meet the require-
ments of his definition is the following : ' Taking a case, say,
of amputation through the thigh, or of excision of the breast,
I should treat the wound in the way following. Having care-
fully arrested all hemorrhage, using most probably the car-
bolised catgut ligature, and having gently removed any
particles of blood-clot that may have lodged on the surface,
employing only clean water or sponges just rinsed out of it, I
should, without any further interference with the surface of the
wound, bring the edges together, adapting these as nicely as
possible with silver-wire sutures. I should not in any way
attempt to close the wound completely, but I should leave
spaces between the sutures, perhaps from one to two inches
long. Then, over the course of the wound and for some distance
on each side of it, I should place a layer of folded lint which
had been previously well soaked in olive or almond oil contain-
ing one part in about 50 of carbolic acid. Over this again I
should place two or more layers of dry lint, either with or with-
out cotton wool ; so arranging this as, by gentle and equable
pressm'e, to secure without any violence, as far as practicable,
the accurate adaptation of the surfaces of the wound through-
out, avoiding thus any considerable cavity in the interior. I
should secure all this by strapping or bandage, or both, so
adjusting these that they may be hereafter removed with the
least disturbance. I should place the patient and the wound
in the most comfortable position possible, having especial
care to the fact that fluids, as they form, may flow outwards.
... As a rule I do not disturb this arrangement for forty-eight
hours, although very often I change the dressing and inspect
the wound after twenty-four. . . . The dressings are removed
with the utmost gentleness, and the state of the wound carefully
inspected. Especially is attention directed to whether there is
any tendency to the lodgment of fluid ; whether that which
forms can escape freely ; whether there is much tension of the
edges. ... If the wound presented no other evidence than
that of satisfactory repair, I should dress it as before, and pro-
ceed in this fashion, dressing and examining it daily or less
frequently, according to circumstances. But if at the flrst
544 RESULTS OF ANTISEPTIC SURGERY.
dressing, or at any time afterward, the discharge became at all
profuse, or the surfaces did not remain in contact, or there
were much tension or a blush at the edges, I should forthwith
substitute a bread and water poultice for the previous dressing,
and probably continue to employ this until at least all the
deeper portion of the wound had closed. When I dressed the
wound, I should wash it probably from the first with tepid
water, perhaps containing some permanganate of potash in the
form of Condy's fluid, or other potent antiseptic of the least
irritating kind. I should accomplish this, washing out, if I
thought fit, portions or even the whole of the interior by the
use of a syi'inge, avoiding contact of sponges or other substances
with the wound. I aim here at the utmost possible cleanliness,
having at the same time due regard to the avoidance of any
unnecessary disturbance, that the process of repair be not in-
terrupted. And withal I endeavour, by means I need not
indicate, to secure for my patient the most complete rest and
the purest air.' Such is the way in which Mr. Savory proposes
to carry out the ' prevention or removal or destruction of all
matter which may prove poisonous.' I do not intend to discuss
whether or to what extent this method will succeed in fulfilling
these requirements ; I leave that for the reader of the preceding
pages to decide. I quote it as showing what the best surgeons
mean by the term ' cleanliness,' and it will be seen that Mr.
Savory's description of treatment by scrupulous cleanliness
does not materially difier from what is ordinarily understood by
that term.
I must now proceed to inquire whether this cleanliness ' is
' It is too much the fashion at the present time to assert that cleanliness,
as the term is now emploj'ed, existed long ago, and to speak of it as an ex-
planation of the results of the aseptic method which has been overlooked
by Mr. Lister. On the contrary, cleanliness as at present understood is one
of the leading developments of Mr. Lister's writings. The disinfection of
instruments, sponges, &c., is the leading feature of his system, and was not
attended to before he wrote. The avoidance of silk ligatures by the use of
catgut ones is due entirely to him, for, though catgut had been tried before, it
had failed, and it was not till Mr. Lister discovered how to prepare it that it
was of any use. Drainage also, though introduced long ago, and again brought
into notice by Chassaignac, was very imperfectly used till Mr. Lister worked
with it, showed its importance, and demonstrated the best mode of employing
it. Cloanliness in the common acceptation of the term is not a feature of
CLEAyLINESS teksijs INFECTIVE DISEASE. 545
really as etfectual in preventing infective diseases as the
methods of treatment founded on the Listerian principle. If
we look at the evidence on this point we shall find, that no
amount of cleanliness, ventilation, &c., has succeeded in
abolishing infective diseases to the same extent as the aseptic
method. This is at once evident if we again look at the com-
parative results in Mr. Lister's own. hands of cases treated
aseptically, and of those treated with antiseptics, &c., i.e. by
scrupulous cleanliness (p. 376). It is still more strikingly evi-
dent if we contrast the results obtained by Professor Spence
(p. 378) with those got by Mr. Lister in the same hospital and
during the same time. For there we find that the total mortality
in JNIr. Spence's practice was very much greater than in Mr.
Lister's, whether we take the results of individual operations or
the total results in the two cases. It will also be seen from
jNIr. Savory's statement at Cork,^ and still better from the
Eeport of St. Bartholomew's Hospital for the following year
(p. 414), that infective diseases are far from abolished by the
use of the ' most scrupulous cleanliness ' apart from truly aseptic
means.^ This is the result in healthy hospitals.
But, supposing that it were the case that these diseases are
abolished in healthy hospitals by cleanliness, free ventilation,
&c., there is abundant evidence to show that these remedies
are but feeble in hospitals which are unhealthy or, as it is
termed, infected. Look for instance at Professor Volkmann's
results before and after the introduction of the aseptic method
(]). 385). Before he employed it he had used cleanliness in its
best sense, that is to say, he had irrigated his wounds with
water and with antiseptics, treated them with the water-bath,
treated them with antiseptics, &c., and yet infective diseases
increased to such an extent that he had resolved to close the
hospital altogether. Nevertheless, as soon as the aseptic
method was introduced these diseases disajjpeared. Perhaps
the most striking piece of evidence on this subject derivable
Mr. Lister's method, for he is glad to allow accumulation of l)lood and dirt
around the margin of the wound, so long as micro-organisms do not enter this
dirt, because it protects the wound from tliu irritation of the antiseptic
employed.
' Jiritixk Medical Jintriidl, August I), 187i).
'^ See also the results of amputations in 8t. George's Hospital, p. 114.
N N
646 RESULTS OF ANTISEPTIC SURGERY.
from Volkmann's experience, is that with regard to the use of
thymol (p. 404), showing that where the antiseptic employed
was inefficient the surgeon mi^ht take the most scrupulous pre-
cautions with regard to cleanliness and yet fail to exclude
infective diseases.
Similar evidence was brought forward by Professor Nuss-
baum (p. 393), and his testimony is the more striking as it is
clear from his results in the country hospital that he really had
been treating his cases with 'scrupulous cleanliness' before he
introduced the aseptic method, and yet his patients were dying
in large numbers from infective diseases in the hospital in town.
Nevertheless as soon as the Listerian method was introduced
these diseases at once ceased. That in his practice ' scru-
pulous cleanliness ' when thoroughly carried out was without
effect is still better shown by the fact to which he alludes, viz.
that even after years of aseptic work with absence of infective
disease, these diseases, of as violent a type as formerly, were
apt to attack wounds not treated aseptically. ]M;my other facts
bearing on this subject will be found in Chapter XVII., and I
need not recapitulate them here.
It follows from what has gone before, that a method which
is ineffectual under unfavourable circumstances has only a limited
usefulness when they are favourable ; for, as soon as from any
cause, accidental or otherwise, the circumstances become
unfav(Mirable, the method becomes ineffectual. In truth
cleanliness alone is no method. To be effectual it must be
combined with careful nursing, efficient ventilation, good
hygienic conditions, careful medical treatment, good surgery, and
so fortli. Eemove one of these conditions, and in proportion to
the importance of the factor displaced does the treatment become
ineffectual. What the aseptic method does is to substitute a
unity for a complexity, and thus to render the patient indepen-
dent of any disarrangement of a number of factors. Exclude
the causes of fermentation from wounds and, as the evidence I
liave brought forward abundantly proves, you at the same time
exclude the causes, whatever they may be, of infective disease.
With the exception of a few extremely rare cases which may
be left out of discussion, the causes of infective disease enter
the body through a wound. If therefore these causes be
CLEANLINESS versus INFECTIVE DISEASE. 547
excluded from the wound, they may be abundantly present in
the surrounding air, and the patient may be in a fit condition, or
in other words, may be a favourable soil for their reception, but
nevertheless he will remain safe. And thus the surgeon has a
feeling of certainty that in spite of the condition of the sur-
rounding air, or the receptivity of the patient, the latter is safe
so long as the means employed to exclude the causes of infec-
tive disease prove effectual. On the other hand, aim merely at
rendering the causes of infective disease inert by a number of
isolated precautions, and the failure of any one of these from
causes overlooked or imknown renders the j^atient liable to be
attacked. There is no certainty, no security, in such a method.
That a patient is liable to be attacked by pyaemia and other
infective diseases, even under the most favourable circumstances,
when he is not treated aseptically, is most beautifully shown
by jNIr. Holmes' experience at the Wimbledon Hospital, and I
do not think that I need apologise for quoting his words in
detail.^ In order to test whether operations would succeed
better in the country than in the town, Mr. Holmes operated
on two patients at Wimbledon. ' I commenced,' says he, ' with
two cases which seemed to me to be very appropriate for the
experiment. One was a middle-aged man suffering from chronic
disease of the tarsal bones, a perfectly healthy individual who
had never, as far as I could find, had any serious disease in his
life, and certainly never suffered from erysipelas. The other
was a man broken down by all kinds of dissipation, and, no
doubt, to a certain extent a bad subject for an amputation, but
otherwise there was nothing very remarkable about the case.
1 sent these two men down to Wimbledon, and performed
amputation on both on the same day, a few days after their
admission into the hospital. They were treated in separate
rooms, neither room having been used before ; one was in one
of the wards of the hospital, the other in one of the private
rooms. They were separate from each other, but attended by
the same nurse ; otherwise they were in exactly the same con-
ditions as a man would be in private practice. The rooms were
entirely free from all possibility of contamination. They were
not attended by medical students at all, but by the resident
• t5cc the debate on Pyiumia. Transactions of the Clinical Socictij, 1871.
N N 2
648 RESULTS OF ANTISEPTIC SURGEEY.
medical officer of the hospilxil. There were no other cases in
connection with them whatever, and all the other cases in the
hospital were simply convalescent cases. I never saw two cases
more likely to do well. One of them was certainly a case of
amputation which anyone would have expected to recover,
merely Syme's amputation for chronic disease. Both of these
people died, one of pya?mia, the other of erysipelas. The
erysipelas did not attack the stump at all, but simply the head.
This appeared on the fourth or tifth day, and was followed
shortly afterwards by sloughing of the skin of the back to an
enormous extent, a piece as large as a soup-plate sloughing a
few hours before his death. The patient died on the fifth day
after amputation. The other man died on the seventh day from
pyaemia.' Argue over these cases as you like, they simply shew
that the contention that cleanliness, isolation, and so on, are
sufficiently protective against infective disease is incorrect, for
by these methods some unknown factor may be overlooked and
the patient become infected.
Dm-ing the debate at the Clinical Society, evidence to the
same effect was brought forward by a number of speakers.
Thus the president, Mr. Prescott Hewitt, mentioned the occur-
rence of pyaemia in his private practice in twenty-three cases.
Mr. Hutchinson also brought forward evidence to show ' that
pyaemia is extremely common amongst the lower animals, and
it occurs amongst them when they are not crowded in the least,
but tuhen they are placed under the most jjerfect hygienic con-
ditions.^ Mr. Charles Hawkins mentioned that an outbreak of
phagedsena occurred in St. George's Hospital in the ward at
the top of the house, ' in the best ventilated and best placed
ward in the hospital.' Sir James Paget stated that pyaemia
was as common in private as in good hospital practice. He
says, after enumerating several cases : — ' I therefore come to
the very clear conclusion that there is really nothing, I will not
say in any hospital, but nothing in a well-managed hospital,
which contributes to the production of pyaemia.' Dr. Barnes,
who had been for some time physician to the ' Dreadnought,'
referred to a great improvement which had followed the aban-
donment of sponges, and the substitution of fresh tow for the
cleansing of each wound, and tlie avoidance as far as possible of
VLEAyLINESS vEERrs INFECTIVE DISEASE. 549
the transference of any contaminating material from one patient
to another. Mr. Croft, who had been surgeon to the ' Dread-
nought,' said with regard to the permanent effect of these
improvements : — ' I know that after some alterations had been
made in the state of the hospital, an improvement took place
in the number of cases of erysipelas, pyaemia, and phagedaena,
but, after a time, while Mr. Tudor was there — I am sure if he
were here he would bear out what I say — both pyaemia,
erysipelas, and hospital gangrene were rife.'
I need not quote other facts mentioned there and elsewhere
to shew that cleanliness, free ventilation, &c., are not by any
means perfect protectors against pyaemia, but are liable to
become ineffective from a variety of causes. I do not of course
mean to deny or detract from the value of cleanliness and good
hygienic conditions.^ On the contrary, they are most excellent
and do much to abolish infective diseases, more especially if
they are associated with free drainage, and chiefly, I believe,
with the open method and antiseptic irrigation. ]My argument
merely is, in the first place, that however well carried out, they
do not even in the most favourable cases protect the patients
entirely from risk, more especially in operations, such as on the
bones, which are particularly liable to be followed by pysemia ;
and in the second place, their success is so much at the mercy
of numerous disturbing causes, many of them unknown and
therefore to a great extent unavoidable, that they cannot form
anything like a guarantee against the occurrence of infective
disease. No one could say of any individual case so treated :
' I have no fear that you will die of infective disease, unless you
are one of those rare individuals who apparently get pysemia
spontaneously : indeed you need not take the danger of infective
disease into consideration.' On the other hand, with the ase])tic
method, whether the operation be conducted in an 'infected'
hospital, or performed on parts particularly liable to be fol-
lowed by blood-poisoning, there is practically, as the evidence
' I do not of course mean to den}' that good ventilation is useful even
where aseptic treatment is carried out. Good ventilation has been shown to
be essential for health, and it therefore ouglit to be carried out as far as
possiljle in everj' case. I speak here of vent ilal ion, kc., as .tiihsiifiitr.t for
aseptic treatment.
550 RESULTS OF AXTISEPTIC SURGERY.
brought forward abundantiy shews, security against its occur-
rence.
The explaiiation of these facts has been furnished by various
writers, and as Mr. Savory has, in his sj^eech during
the debate on Pyaemia and at the meeting of the British
Medical Association at Cork, summarised the points which are es-
sential for understanding the modus ojjerandi of antiseptic sur-
gery, and for showing the necessity for truly aseptic treatment, I
may quote what he says : ' We may take a decomposing fluid,
inject it into the blood, and produce all those effects which are
generally recognised as the effects of pygemia.' The poison ' is
formed during the decomposition of animal fluids, animal fluids
in connection with the living human body.' ' Decomposition is
unquestionably hastened by exposure ' to air. ' Most of all, the
introduction of other matter in a state of active decomposition
increases vastly the rate of decomposition of the original fluid.'
This decomposing fluid ' can, by a syringe, be introduced at
once into the blood of an animal, and produce the most terrible
forms of blood-poisoning.' ' As we have been already told, the
not unhealthy pus, normal pus, may be injected into the circu-
lation, and you do not get as a necessary result, by any means,
pyaemia. But pus is an animal fluid, which, of all fluids, is
most likely to be found in contact with wounds, and, obeying
the law of exposed animal fluids, is exceedingly likely to
undergo decomposition ; and then pus, undergoing decomposi-
tion, will produce pyaemia, as any other fluid will produce
pyjTemia which is in a state of decomposition.' 'Take pus ; you
do not want to go to decomposing vegetable and other animal
fluids; you may do it with them, but take pus, and with it I
could make a case of py;iemia or septicaemia according to order,
by the length of time which I kept the pus before I injected it ;
and I know very well, in experimenting on this subject, one
may produce all degrees of the disease, and may say that the
chances of getting secondary abscesses are in direct ratio to the
length of time an animal lives after it has become inoculated with
the poison. When the poison is thoroughly septic, when you
have that terrible substance which Dr. Bm'don-Sanderson has
shown us how to get in the peritoneal cavity of an animal, the
blood h(;comes so poisoned and spoilt that it kills outright, and
RESULTS OF FERMENTATION IN WOUNDS. 651
there is no time for the secondary effects to supervene.' And
then how is it that this fluid can be in contact with granulating
siu-faces, and yet the patient be free from all symptoms ?
Simply because the granulations protect the patient against
the absorption of the ' terrible substance ' in contact with them.
There are other reasons which I need not mention here, but
the most powerful is that which I have just stated. I again
quote Mr. Savory : ' The best work done in late years in this
direction are those, experiments which Billroth and other
persons have performed, showing that where granulations are
healthy, when they exist in their integrity, they offer a decided
obstacle to the passage of the material from without to within ;
liut when these granulations become destroyed, either mechan-
ically or by other means, whereby they are brought into an
unhealthy state, these fluids pass with fatal facility through
them and so gain entrance into the blood.' I have already
demonstrated that the decomposition of organic fluids and
tissues was dependent on the introduction of particles into them
from the outer world, and that these particles are bacteria or
their spores. The latter point is not absolutely essential for
the question at issue, indeed Mr. Savory sums up the essential
points as follows in his address at Cork. ' I turn away from
any farther inquiry as to the natiu-e of these septic particles. . .
It is enough for us that they are septic; that they can pro-
duce and promote putrefaction ; and further, that fluids so
changed by them may provoke those terrible effects tvhich are
only too well knoivn as blood-poisoning.^ '
T do not pledge myself to all Mr. Savory's conclusions, more
especially where he states that he can get pysemia and septi-
caemia according to the length of time that the decomposing
fluid has been kept or that the animal has lived after inocula-
tion ; but the statements taken as a whole reflect fairly well the
present state of knowledge on this subject, and are sufficient ex-
planation of the results of the different varieties of antiseptic
surgery in regard to infective disease. They shew that no pre-
cautions which do not entirely prevent the growth of organisms
in wounds can be trusted to remove the patient altogether from
the risks of blood-poisoning, for if organisms are not entirely
' The it.ilics are mine.
562 RESULTS OF ANTISEPTIC SURGERY.
excluded from wounds, aud if these wounds are not very care-
fully drained, fluids may be confined in the deeper parts of the
wound and there undergo decomposition. The use of a bread
and water poultice greatly facilitates the putrefaction of the dis-
charge ; and thus it comes about that a patient so treated is
practically only protected from the ' terrible poison ' in his
wound by a thin and delicate layer of granulations. If these
remain whole and healthy all may be well,' but if from ■ some
injudicious movement this layer is ruptured, or if from some
other cause the granulations lose their vigour, then the patient
is liable at any moment to the entrance of the poison into his
circulation, and to the consequent dangers.
Mr. Savory considers that the term ' antiseptic surgery ' is
synonymous w4th the term ' good surgery.' I would ask, if it is
good surgery to leave a patient subject to the risks just mentioned,
and dependent for his safety on a number of factors, any one of
which may fail to act and upset the remainder; or whether it
is not better surgery to keep away altogether from the wound
the causes of the formation of this ' terrible substance,' and
thus make the patient independent of the numberless accidents
which might render him liable to the absorption of the poison,
if it were already present. Cleanliness, isolation, ventilation,
poultices, drainage with gutta-percha tissue, &c., may be very
excellent when suitably combined and carried out, but, as I
have already pointed out, this is a system so complex and so im-
practicable as to be incapable of providing a satisfactory safe-
guard against infective disease ; it is not the simple thing
which some hold it to be. The true simplicity, I again say, is
where there is only one factor to be considered, as in the aseptic
method.
I do not intend to enter in this work into the discussion of
the germ theory of infective disease at all. To do so thoroughly
would require much more space than I have at my disposal ;
and further, its discussion might tend to obscure the real prin-
ciple which is at the basis of antiseptic surgery ; for, as I have
already pointed out, the tendency in the present day is to bring
' This does not by any means always follow, for some forms of micro-
orfi;anisms may be able to j)enetrate through healthy granulations, and produce
infective disease.
MICRO-ORGANISMS AND INFECTIVE DISEASE. 553
prominently forward the germ theory of infective disease, and
thus lose sight of the real points at issue. For my own part,
I consider that the evidence in favour of the germ theory of
infective disease is overwhelming, and I constantly admire the
temerity of those who, often through ignorance of the present
state of knowledge on this subject, ridicule it and speak of it
as far from proven. It is sufficient, however, for our purpose
to recognise that when the precautions taken to exclude
micro-organisms are successful, the causes of infective disease
are also excluded. This is an absolute rule. Look at any of Mr.
Lister's cases which went wrong ; they only did so after fer-
mentation had occurred in the wound, after the aseptic method
had failed to exclude micro-organisms. And so we may draw
this rule, that if organisms are absent from a wound, that
wound having been properly examined, the patient is prac-
tically safe from the occurrence of infective disease. If, how-
ever, organisms are present, he may become liable to these
affections from causes depending on a variety of accidents
which we cannot consider here. This we may accept without
in any way adopting the view that bacteria are the causes of
infective disease, for all that we need hold is, that the pre-
cautions necessary to exclude bacteria are sufficient also to
exclude the causes of infective disease.
That the aseptic system, of all the methods of wound treat-
ment, is the most certain and perfect protector against infective
disease, is perhaps even more strikingly shown by the results
of operations on healthy joints and bones, which are, under
other systems, particularly liable to be followed liy infective
disease. Such operations have been justly looked on as pecu-
liarly dangerous, and as only warranted under exceptional
circumstances, while it is also pretty universally conceded that
if they can be performed subcutaneously, i.e. more or less
aseptically, the danger becomes much less. No other system,
however, not even the most scrupulovis cleanliness and the
most ])erfect ventilation, has ever enal)led the surgeon to cut
freely into healthy joints or to operate on healthy bones, and
\o keep up a communication between the external air and the
injured bone; or joint, witliout incurring tlie greatest danger to
the patient, and that danger cliiefly from infective disease.
.')r>4 RESULTS 01' ANTISEPTIC SURGERY.
And yet the reader has only to turn to Chapters XVIIT. and
XIX. to see that such operations can be done with safety under
aseptic precautions. As I have already discussed these facts
in detail, it would be mere repetition to dwell on them here.
We have thus applied crucial tests to the various systems,
with the view of ascertaining to what extent they may be de-
pended on as barriers against infective disease, and we have seen
that the aseptic method is the one which has done most in this
direction, and, indeed, that under certain circumstances it is the
only one which can be depended on at all. It follows from
this that, as it protects against pysemia, even in the worst cir-
cumstances, it will be equally certain under more favourable
conditions ; and as we have seen that no other method of treat-
ment is anything like an absolute safeguard against infective
diseases in cases liable to be attacked by it, and as these
diseases may occur, as we have just shown, even though rarely,
under the most favourable conditions, it follows that unless any
sufficient reason exists against its use in any particular instance,
Listerism ^ ought to be employed, as far as possible, in all
cases, and where it is not applicable the most strenuous at-
tempts ought to be directed to the limitation as far as can be
of fermentation in the wounds, and to the avoidance of any
distiu"bance such as movement, or anything which tends to
make the granulations unhealthy and thus render the patient
liable to the absorption of the products of fermentation.
But death after operations and wounds is not only due to
infective disease, it may occur as the result of exhaustion,
hectic fever, e^c. Among these the most important are the
deaths which ensue as the result of prolonged suppurations,
most strikingly seen after opening chronic abscesses connected
' I need hardly repeat what I hope I have already made sufficiently clear,
that there is a difference between the terms ' Listerism ' and the ' Listerian
method.' Listerism is the great jJ7-i)icij}le of wound treatment introduced by
Mr. Lister, a principle which may be applied in various ways. The best mode
of application of this principle is that worked out by Mr. Lister himself and
known as the Listerian metliod. Some surgeons have introduced various
modifications of the method, but they still practice Listerism, though not
strictly the Listerian method. Tliat the Listerian method is the be.st mode at
present known of carrying out Listerism cannot be doubted.
DEATHS FROM PROFUSE SUPPURATION. oc5
with carious vertelirne. In this case we have a chronic disease
of the bone, which has led to the formation of an abscess in
connection with it. The cause — the chronic disease of the
bone— which primarily led to the formation of the abscess, was
not very active, and thus the abscess was chronic in its com-
mencement, i.e. not attended with any marked symptom of
inflammation ; the causes — the chronic bone disease and the
tension exercised by the pus already formed on the walls of the
abscess cavity — which induce the continued formation of pus
act very slightly, and thus the abscess increases but slowly,
and if tlie inflammation of the bone cease and the pus be not
very tensely confined in a sac, it may become a cheesy mass or
even be entirely absorbed. As a rule, however, there is suffi-
cient tension on the walls of the sac to lead to continuance of
the pus formation, steady though slow increase of the abscess,
and maintenance of the bone disease. So long as the skin re-
mains unbroken this abscess increases very slowly. If now the
pus be withdrawn by means of an aspirator or by a trocar and
canula, and no causes of fermentation be admitted, it may
happen, though in truth very rarely, that there is no reaccumu-
lation of pus, the residue which was not removed by the aspi-
rator is absorbed, the cavity closes, and the disease is cured.
In some cases repeated aspirations are necessary to secure this re-
sult, but in the majority of instances the abscess steadily increases
in size and must at last be opened, or bursts externally. And
now if no care be taken to exclude the causes of putrefaction,
the state of matters becomes very different from that which
existed before the skin was broken. As we have already seen,
and as the behaviour of the chronic abscess so longf as the skin
is unbroken abundantly shews, pus has no inherent tendency
to undergo fermentation. We also know that the gases of the
air cannot induce fermentation, but that particles in the air
and deposited on surrounding objects can. If the abscess is
opened without sufficient aseptic precautions, of whatever kind
they be, these particles must gain admission into the pus in
the abscess cavity, and as there can here be no destructive
action of the living tissues on these particles, fermentation
occurs. And this fermentation may or may not be putrefactive,
but whatever it be, its products are always more or less chemi-
ooG RESULTS OF ANTISEPTIC SURGERY.
cally irritating ; and the effect of the appHcation of irritating
chemical substances to granulations is to cause them to suppu-
rate. P'urther, these irritating chemical substances — the pro-
ducts of this fermentation — are not transiently applied but are
constantly present day after day in contact with the granula-
tions, for as we have seen, the ' vital ferments ' have an in-
definite power of multiplication, and thus there is a constantly
fresh supply of the irritating products. The result is the pro-
fuse suppuration which constantly follows free incisions into
these abscesses, and the consequence of this prolonged and free
suppuration is hectic fever, exhaustion, waxy infiltration and
degeneration of various internal organs, and ultimately, in the
great majority of cases, death. On the other hand, prevent the
entrance of micro-organisms, as I have shewn can be done by
the aseptic method, and the pus remains as unirritating as
formerly There is no more reason for great formation of pus
after than before the abscess was opened ; indeed, the granu-
lations are relieved from the tension of the pus, and are there-
fore less irritated than before and secrete less. And then in
a few days tlie greater part of such an abscess cavity closes by
adhesion of the granulations, and only a sinus is left leading to
the seat of disease. But the granulations lining this sinus do
not suppurate because they are not irritated, and hence all
that happens is a slight transudation of serum, perhaps not a
couple of minims in a week, and this continues till the disease
is cured and the sinus can close. Thus, during the treatment
the patient is not exhausted by profuse discharge, while he is
relieved from the presence of the abscess, which by the tension
of its contained pus was keeping up the chronic inflammation
of the bone and was a source of constitutional irritation. And
thus we constantly see that, where such abscesses are opened
aseptically and ke^tt aseptic, the patient's health at once begins
to improve.
That these are not mere theoretical speculations, but that
they are fair deductions from the facts, will be evident to any
one who will carefully weigh tlie facts brought forward in the
history of antiseptic surgery and in Chapter XX. For there we
see that the only method of treatment which could be said to
be of any service at all in these cases, excepting the Listerian
DEATHS FROM PROFUSE SURPURATIOX. 557
method, was Abernethy's mode of punctm'ing with a trocar and
canula, or of making a valvular incision into the abscess. On
the other hand, we have the much better results of aseptic
treatment, results not obtainable by the so-called simple
methods of cleanliness, free ventilation, &.c. I need not go
into the discussion of these results again ; the facts have been
sufficiently given in the last chapter.
Though this is the most striking instance in which profuse
suppuration leads to loss of life, yet in many other cases great
danger is caused by its occurrence. Thus in many injuries of
bone, such as compound fractures, very profuse and prolonged
suppuration often follows which may endanger the life of a
weakly patient, or may even in the case of a healthy patient
lead to amyloid infiltration and degeneration of the internal
organs. This is chiefly the case where necrosis of portions
of the fractured bone occurs ; the necrosis may be due to the
injury directly, a portion of bone being deprived of vitality or
separated from its vascular connections at the time of the
accident, but more frequently it is the result of acute in-
flammation of the bone, acute suppurative osteitis, which
supervenes on the injury, and which is due, as is at once evident
from comparison with the behaviour of a simple fracture, to
the existence of a communication between the injured bone
and the external air, and the consequent occmTence of fer-
mentation and formation of irritating products in the wound.
But, if the wound is kept aseptic the fracture behaves exactly
as if it were a simple one, the danger which results from the
external wound being completely avoided. There is therefore
no acute inflammation either of the soft parts or of the bone,
and hence no necrosis from this cause ; the process of repair
at once commences. And, just as in the simple fracture, in
the way which will be described more minutely presently,
portions of bone detached from their vascular supply do not
therefore give rise to suppuration, and indeed, by no means
require removal, but become encroached on and removed by
the surrounding new tissue. Here also this result depends on
the asepticity of the wound, however brought about, whether
by the aseptic method, or in rare cases by absolute immobilisa-
tion or the formation of a crust. If once fermentation occm".s
658 lii:SULTS OF ANTISEPTIC SURGERY.
in the wound, suppuration takes place, detached portions of
bone are always separated, and frequently necrosis of living
bone results. An abundance of facts which prove these views
have also been brought forward. The same remarks apply to
lacerated wounds, though in these cases the suppuration is not
often so great, or at least so long continued, as to endanger life.
Wounds of joints also, though perhaps most frequently fatal
in the iirst instance from saprsemia, septicaemia or pyaemia, yet
when these dangers have become slight, are still serious from
the prolonged suppuration which follows. We have fully de-
monstrated that these dangers are all avoidable by taking
measures to prevent the occurrence of fermentation in the
joints (see Chapter XVIII.)
There are many other cases, which I need not consider, in
which the avoidance of profuse and prolonged suppuration is a
matter of the greatest importance, sometimes even of life and
death. I shall just mention one example more — acute osteo-
myelitis. In this disease, if the patient escapes the primary dan-
gers from infective diseases (see definition of the term in Chapter
XVII.), he is certain to suffer from prolonged and very profuse
suppuration, on account of the death of the bone to a greater
or less extent. To avoid these risks amputation is frequently
resorted to, but recently Mr. Spence has recommended the
excision of the inflamed bone, and has had some good results
from this procedure. Neither of these operations are, however,
necessary if the case be treated aseptically. It is generally
merely requisite to open the abscess freely, wdth the necessary
aseptic precautions, and to attend to free drainage, and as a
consequence suppuration ceases at once or is very slight, and
sometimes the wound heals up without any separation of dead
bone whatever, or if this occurs it is generally merely a super-
ficial exfoliation. Mr. Lister has had several excellent cases
treated in this way. The case of osteomyelitis is of course by
no means so typical as the other instances which I have men-
tioned, because, as we have seen, micro-organisms are always
present in the pus of the abscess in connection with the bone ;
but nevertheless its course, if treated aseptically, is often
markedly different from that which it follows when treated
otherwise, and this, and the fact that some cases do better than
OPERATIONS ON WEAK INDIVIDUALS. 559
others, may be explained by tlie other fact previously mentioned
(p. 256), that in many acute abscesses the micro-organisms are
probably dead when the pus is evacuated.
Then again, if we consider the case of necessary operations
on weak or diseased individuals, we shall find that the aseptic
method more than any other has diminished their risks, and
indeed, with regard to many, alone renders thek performance
possible. The good health of the patient is one of the many
conditions necessary in the sort of treatment which we have
just been considering under the head of cleanliness, free ventila-
tion, &c. If the patient be in a weak state, his resisting power
to septic influences is less, and the protecting layer of granula-
tions is less potent to resist the entrance into the system of the
* terrible substance ' in contact with it. Let the patient be
weak, and he can, for a shorter time, endure the exhausting
suppuration which may follow the operation, a time too short, it
may be, to permit of recovery from it.^ This is a point of view
from which the subject has been regarded by most surgeons
who have adopted the aseptic method thoroughly. Thus Mr.
Wood, at the meeting of the British JNIedical Association at
Cambridge in 1879,^ said of the aseptic method, that one great
reason for employing the Listerian method was ' that it saved
a considerable percentage of weakly constitutions, upon whom
it was absolutely necessary to operate, and who would die unless
for its precautions.' Among these instances may be mentioned
cases of amputation in patients suffering from phthisis. The
difference uf opinion which exists on this subject is of com"se
well known, and many surgeons refuse to operate where marked
' Operations on patients suffering from albuiuiniu-ia scorn to be les:;
dangerous if treated a-septically than a wound is when treated in other ways.
This is easily intelligible, for when not treated aseptically there is frequently
absorption of products of fermentation from the wound. In a healthy person this
may not be of much consequence, the poisonous materials being probably got rid
of in great part by the kidneys. Where, however, the kidneys are diseased
this material may not be got rid cf, but may accumulate in the blood and
poison the patient, or may act on the kidnej's and cause them to stop work-
ing and lead to the patient's death from uncmic poisoning. Both these
dangers arc avoided if the case is treated aseptically, for in that case this
material is not formed in the wound.
- British Medical Journal, vol. ii. IbTii.
560 HESULTS OF ANTISEPTIC SURGERY.
phthisis is pieseut. Of course, where a wound is not treated
aseptically, and where healing does not occur by first intention,
suppuration takes place, and where the patient is weak this
reduces him still further, and, if the wound is large, may only
hasten his death. In these cases also the irritative fever which
occurs is particularly dangerous. Where, however, union
by first intention occurs, irritative fever and suppuration are
absent, and the removal of the disease is a relief to the patient.
As the aseptic system not only favours union by first intention,
but also prevents the occurrence of fever and suppuration in
cases where union by first intention cannot take place, am-
jiutation in cases of phthisis is a much more hopeful procedure
than formerly. Several of jNlr. Lister's cases have been striking
examples of this.
And fui'ther, operations can now be performed which may
be necessary for the recovery of the patient, but which would
have been almost certainly fatal under the former methods of
treatment, and which were therefore considered unjustifiable.
This of course follows from the facts narrated in the three
preceding chapters, for if an operation such as the incision of
a healthy joint may be safely performed for the removal of an
inconvenience, it must be equally safe when performed for the
removal of something which, if left, would imperil the patient's
life. I may quote two facts from Professor Volkmann's speech
at the recent International jNIedical Congress.' ' For a large
enchondroma in the cortal pleura that occupied the left wall
of the thorax. Professor Fischer removed a large piece of the
chest wall and ribs, so that the heart and lungs were exposed
and an opening as large as a child's head was made, and yet the
patient was able to be discharged from the hospital after four
weeks.' ' In the case of a large echinococcus of the liver,
which in front and at the side was covered with thick layers of
liver tissue, and which i)rojected into the thoracic cavity, after
resection of the seventh rib, I opened the healthy pleural
cavity, which was free from adhesions. The thorax was freely
opened, the thinned diai)hragm cut into, the echinococcus sac
opened, the animal bladder extracted in toto, and the patient
recovered without complication. A similar operation with like
results was conducted by ]Mr. Israel of Berlin.' On this point
' Si'C Lancrt, AuiTiist 18, 1881.
■LISTERISM AIDS CONSERVATIVE SURGERY. 561
also Mr. Wood says : ' ' And another point from which he ' (Mr.
Wood) ' had been in the habit of considering it ' (the aseptic
system) ' was this : that it extended the aim and scope and
value to the community of surgical skill in eases on which it
would be too risky to operate without the extreme precautions
which antiseptic surgery affords. There were a great many
operations which they were doing at the present time which
would have been considered wild, and which were now by many
considered unjustifiable, otherwise than with their improved
means.'
There are, however, a great many other points which have
to be attended to in the treatment of wounds besides the saving
of life ; we have to look to what Sir James Paget calls the ' w^ell-
doing ' of the patient. Now as the aseptic method allows the
performance of operations which would otherwise be considered
unjustifiable, it is evident that it must in many cases enable
the surgeon to render the patient a more useful member of
society than he would otherwise be. Take, for instance, any
interference with the movement of joints from some cause (say
the presence of an exostosis) which would involve the o})ening
of a great articulation in its rectification ; here the aseptic
method permits an o})eration which would not otherwise be
possible. Look at Mr. Lister's list of joint cases, and see
whether or not some of the patients have been rendered more
useful members of society by the aseptic method.
Take the simple operation of tenotomy. How impossible
it was till the subcutaneous method was introcUiced ; but as
soon as a method was found by means of wliicli the causes of
fermentation were excluded from the wound, tliese operations
became frequent, and they certainly daily increase the use-
fulness of many patients. And what was im})ossible in this
department in former days by means of free incision, is possible
n<jw ; arid if for any reason one wislies to see the tendon to be
divided, it may be exposed aseptically without fear of the result.
And further, in cases of ruptured tendons, cases so a})t to leave
inii»aiied power behind, one may cut down and sew the ends of
the tendon togetlier with catgut and in this way get perfect
' Lie. rit.
562 BESULTS OF AXTISUrTIC SUEGEEY.
union and a complete restoration of power. This has been
done in a number of eases with perfect success, and I may refer
to Eschenburg's thesis, published in 1877, for the history of
these attempts and their results. I may quote two passages
from this thesis which shew a striking contrast between the
results of septic and aseptic surgery. The first is taken from
Eavoth, who says : ' Selbstverstandlich wird man die Sehnennaht
vermeiden, wenn keine Hautwunde gleichzeitig vorhanden ist.'
On the other hand, Kiister writes as follows : ' Es ist nun eines
der Hauptverdienste der antiseptischen Wundbehandlung dass
sie den Kreis unserer operativen Indicationen wesentlich
erweitert hat, dass sie dem Chirurgen mit ruhigem Gewissen und
ohne die mindeste Besorgniss an eine Anzahl von Operationen
zu gelien erlaubt, welche sonst entweder gar nicht, oder nur
unter ganz besonders giinstigen Bedingungen unternommen
werden durften.' And among these operations are those of
stitching ruptured tendons.
This is only one example of the numerous applications to
which a method can be put which renders operations practically
subcutaneous. Look also at all the operations for ununited and
badly united fractures, and for deformities of bones, operations
to aid the reduction of dislocations, more especially when of
old standing, radical cure of hernia, and so on. These instances
are so numerous and varied that I cannot detail them here, but,
in the practice of the operating surgeon, cases are constantly
occurring in which the advantages gained by means of the
aseptic method are of the greatest importance.
While the scope of the operating surgeon is so much
increased by the aseptic method, the cause of conservative
surgery is also greatly advanced. I have at p. 442 shewn that
in cases of disease of joints a cure may be obtained in a large
proportion of instances, without resorting to any further ope-
rative procedure than the free incision of the diseased articula-
tions. By this treatment not only is the limb retained without
any shortening, but also there is frequently a considerable
amount of movement in the articulation, a result of the greatest
importance to the patient. In the treatment of compound
fractures, also, there is much less necessity than formerly for
amputation, either primary or secondary. This is hardly a
. LISTERISM AIDS CONSERVATIVE SURGERY. 563
point which can be treated by statistics, but my own experience
— and it is the same as that of others who have practised careful
aseptic treatment, and a careful perusal of the cases in Chapter
XIX. will demonstrate it — is, that the necessity for these mutila-
tions is very much less than when other methods are employed.
A limb must be very badly injured indeed before it is necessary
to perform primary amputation : it must not be merely that a
joint is opened, or that the bone is extensively comminuted or
the soft parts badly lacerated: the questions really are, whether
the part beyond will retain its vitality, whether if it does so it
will be useful, and whether there is a fair probability of purify-
ing the wound. If the last is probable the chance of
recovery should be given, and if afterwards it is found that
purification is not successful, and if otherwise the injury is one
which, without aseptic management, would demand primary
amputation, the operation can be performed in two or three
days after the injury — as soon, in fact, as it becomes evident
that aseptic treatment is impossible.^ Again, where primary
amputation is necessary it need not be performed above the
injiu-ed parts, but, with the view of getting a longer limb,
where that would be an advantage, bruised and even lacerated
parts may be included in the stump ; for inflammation will
not occur in the flaps, and hence the sloughing which would
otherwise take place is avoided. I have myself seen limbs
amputated in the practice of septic or semi-antiseptic surgeons
which I know could have been easily saved by aseptic manage-
ment ; and I have, on the other hand, known the surprise of
surgeons when amputation has been performed through the
bruised parts in order to get a longer stump or to save an
important joint, and their expectation that the injured parts
' This statement may seem contrary to the well-known facts as to the
dangers of secondary amputations, but here the case is different ; for under
ordinary circumstances the (question of secondary amputation does not arise
till it is found that tliere is danger to the patient if conservative treatjnent is
persisted in. Here, however, I do not advise that one should wait till the
patient is in a dangerous state ; I merely say that attempts may be made to
save limbs which would otherwise be certainly amputated, and that if it is
found that fermentation has not been avoided, then the limb ouglit, in the
majority of these severe cases, to be amputated as soon as it is evident that
the attempt to purify the wound has failed, without waiting for the appearance
of any constitutional symptoms.
o o 2
6G4 RESULTS OF ANTISEPTIC SURGERY.
would slough 'when inflammation came on.' But fortunately
inflammation is not likely to come on if the wound has been
properly treated.
I need not discuss this matter further. If one remembers
that an incision, supposing it can be made aseptically, provided
also that the wound is kept at rest and otherwise properly treated,
is not followed by any local reaction nor by constitutional dis-
turbance, one can readily realise how many little operations
of convenience may be performed with benefit and increased
usefulness to the patient. It may be argued against such
operations of convenience that man is fallible, and that a failure
of the method might prove a serious matter to the patient.
This is to a certain extent true, but the chances of failure in
experienced hands in any given case are very small indeed.
The performance of such operations by those just learning the
method cannot be too much discouraged. It is too much the
fashion nowadays to begin aseptic work with some of these
daring procedures, such as opening joints ; but such operations,
however simple they appear, ought not to be lightly under-
taken ; indeed they ought not to be attempted till one has had
extensive experience in the aseptic treatment of wounds, and
more especially of chronic aliscesses.'
Exjjerience is needed in aseptic work just as in every other
department of surgery. Why does the student devote so much
of his time to learning anatomy and to acquiring manual dex-
terity in the use of the knife? Simply in order that he may
be able to operate with safety to the patient. Take the opera-
tion of ligature of an artery or lithotomy or any other great
operation in surgery. When performed by an experienced
surgeon it seems very simple and easy of performance, but the
young operator finds that nmny ditficulties have to be over-
come and many little arts acquired before it can be done
in the same way as by the ex})erienced surgeon. One would
never dream of allowing a man who had never handled a knife
' Surgeons are loo apt, even without liaviiig had any experience of the
aseptic method, at once to introduce luoditications wmch generally are illogical
and hurtful. Volkniann {Lancet, August K'>, 1881) makes the following true
remark on this point : ' Most of tlie unfavoinable judgments,' says lie, ' passed
nn this metliod afe due to the fact that surgeons who have not yet learnt to
experiiuent ivitli it have already made it the .siihjcut of their experiments.'
EXPERIENCE NEEDED FOR ASEPTIC WORK. 565
before to commence with one of these operations on the living
human body. It is just the same with aseptic surgery. For
its proper practice are required a scientific training, and more
especially, a training in experimental work with its consequent
acquirement of patience and dexterity. Let the beginner com-
mence its practice in simple wounds where but little harm will
result from his failures, or, better still, let him try some experi-
ments on fluids contained in flasks. Then, just as the operator
feels his way to more serious operations, so the surgeon operat-
ing aseptically extends the application of his method ; and just
as the experienced operator may proceed with confidence to
operations which in the hand of an inexperienced man would
be very doubtful procedures, so the surgeon practising Li sterism
may with confidence in its protection perform operations which
would otherwise be unjustifiable, such as many of the opera-
tions of convenience of which we have been speaking. He has
then chiefly to consider whether the advantage to be derived
from the operation is worth the inconveniences attending its
performance. Of course if one has to deal with a large num-
ber of cases one cannot say that all of them will do well : in
some one or other the experiment may fail. Where there is a
large number of cases or a continuous run of successes the sur-
geon may become less particular than in any special case which
he has determined to keep right, and an accident 7::aight occur.
But we may fairly put the matter in this way : given any
single case, say of incision into a joint, the surgeon may reckon
with certainty that in that particular instance no harm will
result from the operation. When, therefore, the surgeon under-
takes one of these serious operations he should realise the
dangers which are run and the means of avoiding them, and
should devote his most careful attention to the case in ques-
tion throughout the duration of the treatment. If this is done
it is right to undertake such operations if their performance
can increase the usefulness of the patient.
I have said that operations performed aseptically, where the
wounds remain aseptic and wliere they are properly treated
otherwise, are not followed by any local or constitutional dis-
turliance, and I must now say a few words on tins point. And
56G RESULTS OF ANTISEPTIC SURGERY.
first with regard to tlie local progress of a wound treated asep-
tically.
Where the wound is treated aseptically by the method
formerly described (where the drainage is efficient, where the
stitches are not too tight, and where tliere is no other local
cause of initation, such as movement), no inflammation occurs ;
there is no swelling nor redness of the edges, as is so frequently
the case in wounds treated otherwise. The skin around the
wound remains as pale and as lax as it was when stitched up at
the time of the operation ; there is no evidence of reaction.
Thus it comes that such wounds are quite painless, and their
edges may be pressed and handled without occasioning the
patient any uneasiness. Hence even after the most extensive
operations the patient remains free from pain ; indeed, the opera-
tion being performed under an anaesthetic, and there being no
inflammation afterwards, the whole treatment from beginning to
end is unattended by any suffering. Patients constantly express
their astonishment that the pain which they perhaps mostdreaded
is absent ; and this astonishment is the greater if the patient
has been previously operated on and treated by the older
methods. •
Then, as the result of this absence of inflammation, the scar
is linear and soon becomes hardly apparent. One or two sur-
geons have stated that the scars after wounds treated aseptically
were conspicuous, and that therefore the method was unsuitable
for wounds on exposed parts. This statement must, however,
rest on some mistake — either protective has not been used or
some other error has been committed ; for my own experience,
which is now very extensive, is, that an inconspicuous and
linear scar is one of the most striking results of the treat-
ment.
But not only is there absence of inflammation along the cut
edges of the skin, it is also absent from the deeper parts of
the wound. Thus there is no suppuration even where the deep
structures are not absolutely in contact. The discharge from
the drainage tube is purely serous and rapidly diminishes in
amount so as to render the drain unnecessary in a very short
time.
The importance of this absence of inflammation in the
PROGRESS OF WOUNDS TREATED ASEPTIC ALLY, mi
deeper parts of the wound has been well shewn by the advan-
tages gained by the application of the method to experiments
on the lower animals. This is perhaps best illustrated by the
experiments recently performed by Professor Gerald Yeo on
the brains of monkeys.
In Dr. Ferrier's former experiments on the brains of mon-
keys for the purpose of investigating the function of the
various parts of the brain, no attempt was made to keep the
animals alive after the operation, because, as the result of ex-
perience, encephalitis was looked on as a certain consequence.
The attempts which were made failed owing to the occui'rence
of encephalitis, with the exception, I think, of one animal
which lived for some time. It was therefore deemed useless to
attempt to preserve the animals, for the after effects of the
injury done at the time of the operation were so complicated
by the effects of the inflammation which succeeded, that results
of any value could only be obtained from observations made at
the time of the operation.
Lately, however (1878-80), Gerald Yeo has performed
a number of these operations with aseptic precautions, and the
results were extremely striking, and yielded very definite and
valuable information. Twenty-six operations were done. In
the first case great difiiculty was found in retaining the
dressings in position, and this animal tore off the dressings.
It died in a short time of encephalitis, and was the only one out
of the twenty-six in which inflammation occurred. Afterwards
a very convenient and satisfactory mode of fixing the dressings
was devised, and this accident did not happen again. In the
other twenty-five cases no inflammation whatever occurred, as
was confirmed on post-mortem examination of the animals
which died shortly after the operation, or which Avere killed
after a sufficient length of time had elapsed. As no inflamma-
tion occurred, the symptoms which were manifest after the
operation were due to the lesion caused at the time, and thus
valuable and definite facts were elicited. The gain to physio-
logical observation indicated by these experiments cannot be
over-estimated.
Of the twenty-six cases operated on seven dit'd, the
remainder surviving the operation permanently, without ever
508 RESULTS OF ANTISEPTIC SURGERY.
presenting any symptoms except such as were due to the
cerebral lesion. Of the seven deaths, one — the first case, in
which the animal tore off his dressings — died of encephalitis ;
two died soon after the operation, one from chloroform and one
from shock ; one died six days after the operation from cerebral
hemorrhage, and here there was no trace of inflammation ;
three died apparently from the intense cold of winter, one of
these surviving the operation for thirteen days without a trace
of inflammation. The wounds always healed by first intention,
and the dressings were dispensed with in about a week.
As a result of this absence of inflammation in the deeper
parts the scar does not become adherent but remains movable.
This is of greatest importance after amputations where so much
inconvenience is often caused by the adhesion of the scar to the
divided end of the bone.
This absence of inflammation is also well seen after opening
bursse or hydroceles. Of late it has become very much the
fashion in Germany to treat hydrocele by making an incision
into the sac aseiitically, stitching the tunica vaginalis to the
skin by means of catgut, and inserting a drainage tube. No
inflammation follows this procedure ; the discharge becomes
very slight, the drainage tube is removed in a day or two, the*
wound heals, and the hydrocele is cured. (The violent inflam-
mation which follows incisions into hydroceles without aseptic
precautions is well known.) Similar residts are obtained in
cases of bursitis, more especially of bursitis in connection with
the sheaths of tendons. Incisions may be made into these,
the fluid and solid material evacuated, and a drainage tube
inserted, without fear of bad result, and with ultimate cure of
the disease without any adhesion of tendons or other accidents
which commonly follow such attempts.
In cases treated aseptically the wound heals as a rule much
more rapidly than when it is treated otherwise ; for where the
edges can be brought into contact, healing by first intention
is the rule, and even where there is a sj)ace left, this becomes
filled up with blood clot which rapidly undergoes organisa-
tion.
"^riie organisation of the lilood clot is one of the most marked
features in aseptic treatment. That blood clot may become
ORGANISATION OF BLOOD CLOT. 669
organised under certain circumstances is no new fact in medi-
cine or surgery. We all know what happens in subcutaneous
injuries. Blood clot and lymph are thrown out, they are gradu-
ally removed by absorption, or their place is taken to some
extent by new tissue. In a simple fracture blood clot and
lymph are present between the ends of the fractured bone.
The effused material gradually disappears, and its place is taken
by new tissue which ultimately ossifies. So after tenotomy ;
the space between the ends of the divided tendon is filled up
with blood clot and lymph, and these become organised, and
thus imion again occurs. I need not bring forward other
examples to show that blood clot in the living body, when
protected by the skin, is gradually removed and its place taken
by new tissue. In an open wound not treated aseptically the
blood clot generally putrefies, and, as a result, breaks down,
liquefies, and is washed away with the discharges ; the surface of
the wound granulates, and thus healing takes place. Where,
however, a wound is aseptic, and where it is protected from
other sources of irritation, such as the action of the antiseptic
employed, the blood clot in it undergoes the same changes as
it would under the skin, for the aseptic method renders wounds
practically subcutaneous. Thus it does not break down but
remains, filling up the wound with a solid brown mass ; no
granulations are seen, nothing but this brownish solid material.
After some days, if this clot be scratched, it will be found to
bleed, implying that new vessels have been formed in it, and
on lifting up the edge of the clot a broad margin of cicatrix
will often be found. If the clot is left undisturbed it fre-
quently happens that after a time a superficial layer of
toughish brownish material (old blood clot) may be peeled off
and a complete scar found underneath. In some cases organ-
isation occurs in the clot up to the level of the skin, and
cicatrisation spreads for some distance under the superficial
unorganised layer, and then by-and-by the remaining central
portion granulates, and we have a small superficial granulating
sore which rapidly heals. The occurrence of granulation may in
this case, I think, be due to the entrance of micrococci, which as
we have seen sometimes occurs at a late period of the case. If
there is much movement of the wound, or if no protective
570 RESULTS OF ANTISEPriC SUliGEIiY.
be employed, this organisation may also be imperfectly or not
at all observed. The organisation of blood clot has been de-
monstrated by several writers, and therefore I need not describe
it minutely. The process essentially consists in this : young
cells (whether white blood corpuscles or derived from the con-
nective tissue, or both, is not yet determined) pass into the
blood clot and gradually form fibrous tissue and vessels, which
become connected with already existing ones, according to
the various well-known methods of vascular formation. This
process gradually extends to the surface till, after some days,
as I have said, the blood clot bleeds when scratched. When
organisation has sufficiently advanced, the epidermis spreads
from the edge. The original blood clot takes no active part
whatevier in this process : it forms a mould in which the young
cells develop, and is gradually either used up as pabulum for
these cells, or removed by absorption. Here, just as when sub-
cutaneous, the original blood clot disappears, and its place is
filled by young tissue which developed in it not from it.
Sloughs are served in the same way. When a part under
the skin dies, as is frequently the case where infarcts occur,
it does not necessarily separate, it is gradually removed by
absorption and its place is taken by new tissue. In the same
way a slough of the skin if kept aseptic, and not imbued with
carbolic acid or otherwise rendered irritating, does not separate
but goes through the same process as the blood clot. The
ordinary process of separation of sloughs is the occurrence of
inflammation at the line of junction of the living with the
dead tissue owing to the irritating character of the latter.
(The slough causes inflammation because it is undergoing de-
composition, for the products of decomposition are irritating.)
But if the slough is not chemically irritating it does not
cause this inflammation ; it does not irritate the living parts
around. Then the young cells pass into it as into the blood
clot, and the whole process is exactly the same. Thus in
lacerated wounds, if rendered aseptic and kept free from the
irritation of the antiseptic employed, suppuration and sloughing
do not occur: the raw surfaces and the interstices between
the torn pieces of tissue become filled up with blood clot, the
process of organisation just described goes on, and the whole
ORGANISATION IN CATGUT. 571
or the greater part of such a wound may heal without the
occuiTence of granulation, suppuration, or sloughing. A similar
process has been observed in dead bone kept aseptic and not
loose : the granulations gradually encroach upon it, and it soon
entirely disappears by absorption.
The same process occui's in catgut introduced into a wound,
whether for the puq^ose of ligaturing vessels or as a drain.
The young cells gradually infiltrate the catgut from without
inwards,' develop into fibrous tissue, remove the original cat-
gut, and take its place. The ordinary process of separation of
a silk or hempen ligature is, that fermentation occurs in the
discharge which has soaked into it ; the ligature thus irritates
the walls of the vessel on each side of it ; these granulate, and
then suppuration takes place at the point of contact of the
dead part included in the loop of the ligatm-e with the living
tissue. When suppuration has occurred all round on both
sides the ligature is loose and may be pulled away. Secon-
dary hemorrhage results when the portion of the vascular wall
which has undergone degeneration into granulation tissue as a
consequence of this process is not strong enough to resist the
blood pressure. If, however, a hempen ligature be applied
around a vessel and the wound be kept aseptic, the ligature
remains chemically unirritating and may never separate at all.
I have seen this well illustrated in a case of amputation where
the surgeon operated aseptically, but tied the vessels with hem-
pen ligature and left the ends hanging out: the ligatures
would not separate but had to be broken short inside the wound.
If now catgut be employed it is a material which is rapidly
removed by the young cells which, as I have previously said,
infiltrate it, and its place, as a ring round the vessel, is taken
by this young tissue, which rapidly becomes organised and
replaced by a ring of newly formed fibrous tissue. Thus where
a catgut ligature is employed there is no ulceration of the
' The great advantage of the new catgut prepared with chromic acid is
that the cells have a great difficulty in peneti'ating it, and therefore onl}' erode
its surface, and thus a stitch which luis been left in the wound for some days,
though narrower where it has been in the tissues, is still firm and free from
cellular infiltration. With catgut prepared by the older uiethod cells infiltrate
it in a few days. With unprepared catgut the cell infiltration and tlie
absorption of the thread is a very rapid process.
572 RESULTS OF ANTISEPTIC SURGERY.
coats of the vessel, but after a time a ring of newly formed
fibrous tissue will be found in the situation of the original
ring of catgut. For these reasons also the risk of secondary
hemorrhage is reduced to a minimum.
The facts with regard to the organisation of the catgut liga-
ture were described by Mr. Lister in his first publication on
the subject as long ago as 1869,' and as some of his state-
ments have been misunderstood I may quote what he says. It
has been supposed by some that he held that the dead blood clot
and that the dead catgut became revivified in the tissues. Such
an idea is of course utterly absurd and was never entertained
nor expressed liy Mr. Lister. Indeed, he speaks as follows as
regards the blood clot, and applies his remarks to catgut : ' Thus
the dead, but nutritious mass, had served as a rtiottld for the
formation of new tissue, the growing elements of which had
replaced the materials absorbed, so as to constitute a living
solid of the same form.' Mr. Lister tied the carotid artery of
a calf in two places with a ligature of catgut (in one place with
two ligatures), and a month later he killed the calf and ex-
am^ined the parts. He says : ' The two pieces of catgut which
had been tied round the vessel at the distal part had become,
as it were, fused together into a single fleshy band, inseparably
blended with the external coat of the artery. The knots were
nowhere discoverable, and the only indication of the end
which had been left long at the time of the ojieration was the
presence of a black speck ' (the original material contained
dark mineral impurities) ' here and there upon a delicate thread
of cellular tissue in connection with the vessel. The cardiac
ligature was in like manner continuous in structure with the
arterial wall. The short ends had disappeared ; but the mas-
sive knot was represented by a soft smooth lump, which ap-
peared at first entirely homogenous, except that it was speckled
with dark particles as before referred to. On section, however,
I discovered in the interior of the mass, and lying close to the
wall of the artery, a small residual portion of the original
knot, of comparatively firm consistence, and with the threefold
twisted character of the cord plainly visible. It was quite dis-
tinct from the living tissue, so that it could be readily picked
' Lancrt, April 3, 18C0.
ORGANISATION OF CATGUT. 573
out from its bed with a pair of needles.' Here almost all the
original catgut had been removed, but it had served as a mould
for the development of new tissue Avhich had taken its place,
and which retained the form of the mould in which it had
grown. Mr. Lister describes the microscopical appearances as
follows : ' A bit of the residue of the peritoneal thread, having
been teazed out with needles in a drop of water, presented, like
a fresh piece of peritoneum, the wavy bundles of parallel fibres
characteristic of perfectly developed fibrous tissue. Adhering
to the surface of the remnant of the ligature was some soft
opaque material, readily washed off with water, consisting of
corpuscles of different forms, most of them caudate or fibro-
plastic, but some spherical, though not resembling those of
pus ; and here and there fragments of the original peritoneal
tissue, affected more or less with interstitial cell-development.
At a short distance from the remains of the old thread, the
fieshy material which had been formed at its expense proved
to be a most beautiful example of fibro-plastic structure, the
coarse fibres which mainly constituted it being composed
of very large elongated cells, often containing several nuclei,
and presenting in their course branchings and thickenings of
various forms. Here and there were some fibres more per-
fectly formed, and also cells of a more rudimentary character.
Again, the band which had resulted from the organisation of
the two fine threads of catgut, which, from the smallness of
their bulk, had no doubt vanished early, having had longer
time to perfect its structure, was a comparatively well deve-
loped form of fibrous t,ssue, consisting of coarse fibres rather
than of elongated cells, being thus intermediate between the
merely fibro-plastic material of more recent growth and the
completed texture of the original thread.'
A number of writers have described the changes which
blood clot and portions of dead tissue undergo in the process of
organisation. One of the most interesting and thorongli inves-
ligations on this subject has been made l)y Dr. H. Tillmanns of
J/cipzig.' Tillmanns took portions of the liver, kidney, spleen,
' Experimeiitcllc imd aiiatomischu UnlLa-sucliuii^cn iilier W'umUni (lor Leber
und Niere. Ein iieilraj^ ziir Lcluu V(jii dur anli.supli.schcn Wundbcilunj^.
Virchow's Archir. Ud. 78, IbT'J.
674 liESULTS OF AUTISEPTIC SURGERY.
and lungs of rabbits, and hardened them in absolute alcohol
for one to three weeks or longer. Pieces of these hardened
dead tissues were then introduced with aseptic precautions
into the peritoneal cavity of rabbits (in each case several pieces
were used) ; after some days the animals were killed and the
state of matters investigated. Twenty animals were experi-.
mented on, and into their peritoneal cavities about 100 por-
tions of tissue were introduced. The animals did not appear
the worse for the operation ; the temperature remained normal,
and they seemed well. Of these twenty animals only two died,
both of acute peritonitis : in one case an en-or was committed
in the treatment, the stitches were removed too early, and the
intestines protruded : in the other case the animal was suffer-
ing before the operation from chronic peritonitis which after-
wards became acute. When the animals were killed early, in
a day or two after the operation, the masses of tissue were
found to be adherent to some part of the peritoneum, and
sometimes two pieces of tissue were attached to one another.
Where fourteen days or more were allowed to elapse, the por-
tions of tissue were found firmly adherent and much diminished
in size, evidently undergoing absoqjtion ; in some places there
was only a thick layer of new material containing a pulpy mass
in its interior. In one animal into whose abdominal cavity a
whole kidney had been introduced, and which was allowed to
live for forty-seven days, the kidney had entirely disappeared ;
the only thing noticeable was that at one part of the omentum
there was a thickish tough spot, where probably the absorbed
kidney had been attached. On investigating the process micro-
scopically the following were briefly the appearances found :
After twenty-four hours the mass of tissue is, as I have just
said, adherent to the peritoneum and surrounded by a layer of
soft new material — lymph. Any defects which existed in the
margin of the specimen are filled up with this soft mass.
This new material when examined is found to be composed
of countless numbers of cells, which Tillmanns holds to be
white blood corpuscles. If two pieces of dead tissue lie close
to each other, they become adherent to each other by means of
this material. If these tissues are examined at a later period,
say forty-eight or seventy-two hours after their introduction,
ABSORPTIOX OF DEAD TISSUE. 575
these cells are found to have increased in number and to be
no longer confined to the outside of the organ, but to have
penetrated into it where possible, forming, as Tillmanns puts it,
streets and pathways of cells through the tissue. Thus, for
example, in the case of the liver these cells penetrate in the
first instance along the streaks of connective tissue which lie
between the lobules, entering first those channels which are
largest but gradually spreading along the smaller ones. At
this time the cells have already begun to develop to higher
tissue, and not merely round cells, but also elongated spindle-
shaped cells undergoing further development, are found. P^ig. 39,
Plate v., represents this : to the right is seen the old liver cells,
and to the left the new cells which have penetrated along the
interlobular connective tissue ; at the upper part these cells
have already become spindle-shaped. This process gradually
goes on, the young cells penetrate more and more among the
dead materials, which gradually disapjjear by absorption, their
place being taken by this young tissue which has come from
without. This tissue rapidly undergoes further development
into fibrous tissue, vessels, &c., according to the well-known
processes (see fig. 40, Plate V.). The contraction of this
young connective tissue and the further changes which it
undergoes lead to the disappearance of the original mass and
the formation of a cicatrix at its site, which also, as time goes
on, tends to dwindle and disappear.
Thus the replacement of blood clot, sloughs, and other
dead tissues, in the living body by new material — their organ-
isation, as it is commonly called — is no longer a fact resting on
clinical experience alone, but is a process which has been traced
step by step under the microscope. What at first sight seems
remarkable, what is certainly something new, is, that this
process occurs in an open wound. But when the whole facts
are carefully considered, it will be seen that this ftict is only
one which might have been expected, and that it is quite in
accordance with well-known facts in pathology.
While there is this absence of local disturbance in wounds
treated aseptically, the constitutional state of the patient re-
mains good ; in fact, if he has not lost much l)lood during the
576
BESULTS OF AyTISEPTIC SURGERY
operation, or if the operation has not caused shock, he is, on
recovery from the effects of the chloroform, practically as well
as before. His appetite is perfect, and I may say here that
after operations performed aseptically there is no reduction of
diet even for a few days ; an hospital patient remains on full
diet, and a private patient may have anything he fancies pro-
vided it is wholesome, and the more nutritious the food the
better. Indeed, after the opening of a psoas abscess, or after
an operation which rids the patient of some depressing disease,
such as a carious joint, the appetite which was previously
very imperfect returns in a few days, and hunger becomes the
jBBSEBEflEB
jJBb
Fig. 80. — Temperature Chart.
Temperature chart from a ca-ie o£ ilacEweii's operation for double genu valgum (Case 69, p. 488;.
patient's chief trouble. At the same time there is no fever, as so
frequently occurs after operations treated otherwise. I do not
propose to discuss here the subject of temperature after opera-
tions ; to do so would require much space, and our knowledge
of the origin and regulation of temperature changes in the
living body is as yet so imperfect that we could not come to
any definite conclusions. I shall therefore content myself with
referring to the following facts.
After an operation performed aseptically, and in which there
is no cause of elevation of temperature, such as tension, the
temyjerature remains normal ; or if the operation has been at all
extensive, the following changes are obsei'ved, of which Chart
XXXVI., fig. 78 (Case 69, p. 488), is a very good example.
In this case both femora were divided, i.e. a compound fracture
of each femur was made, on the same day : the temperature
previous to the operation was 99° F. : on the evening of the
TYPICAL TEMPERATURE IN ASEPTIC CASES. 577
operation it had fallen to 96'8° : on the following morning it
was 100-6°, and then it again rapidly fell to the normal, being
on the same evening 99'3°. As a rule the temperatin-e after
operations performed aseptically resembles this example : the
temperature is below the normal on the evening of the opera-
tion, it then rises to or above 100°, reaching its highest point
on the following morning or evening, and then rapidly falls to
the normal line again. In some cases before reaching the
normal it fluctuates for a day or two between 99° and 100°, but
this fluctuation is not within the range of fever temperature
but within the normal rauge.^ It is very seldom that the
pulse rises in equal proportion, indeed it generally remains
normal.
This normal^ temperature may be disturbed for various
reasons, but especially when tension and retention of secretions
occur. The elevation of temperature which follows imperfect
drainage is often very marked. Among the cases narrated in detail
there is no good example of elevation of temperature from tension:
I may therefore quote the following instance. A little boy had an
unreduced dislocation backwards of the bones of the forearm of
six weeks' standing. On December 9, 1876, Mr. Lister cut
down on each side of the joint, opened it, and succeeded, after
detaching the muscles from the condyles of the humerus, in
reducing the dislocation. The parts were very tense after
reduction, and the primary rise of temperature reached 101° on
the day following the operation, and remained at that level for
thirty-six hours ; it then fell rapidly as usual. On December
14th Mr. Lister moved the joint for the first time. That even-
ing there was profuse hemorrhage, which ceased on removing
the dressing. A fresh dressing was applied, but the hemor-
rhage went on into the limb, which was next day very much
swollen and distended with blood. The temperature rose
rapidly and continuously till it reached 104*4°. On December
16th incisions were made into the arm to evacuate the blood
' It has been pointed out by Wunderlich that after disturbance of the
temperature the curve often fluctuates for a day or two before regaining the
normal.
- Mere elevation of ten^pcrature without other symptoms cannot be called
fever. Fever is indicated by a combination of symptoms, and an elevated
temperature is only one, though the most striking, feature of the febrile state.
P P
678
RESULTS OF ANTISEPTIC SURGERV
clots ; on the following day the temperature began to fall, and
on the morning of the iHth was 100-8°. After some oscilla-
tions about this height it rapidly fell to normal. Here in the
first instance, coinciding with tension of the parts after the
operation, the primary rise reached 101°, and did not fall at
once, but remained for some hours at that height. Then it
fell ; but the parts became greatly distended with blood, there
was great tension, and coincidently with this the temperature
rose rapidly and to a consideral^le height, and again fell when
the tension was got rid of. The pulse at the same time in-
creased in rapidity, being on one occasion 144.
XXIII
Fig. 81. — TEilPEKATLfKE FROM A CASE OF COMPOUND FRACTURE, IN WHICH
THERE WAS GREAT DIFFICULTY IN RETAINING THE FRAGMENTS IN
POSITION (Case 27, p. 472).
Why it is that the accumulation of discharges and the con-
sequent tension should be accompanied by rise of temperature,
often very rapid and high, is a very debateable question, and
one which can hardly as yet receive an answer. At first the
impression was, that this rise of temperature was due simply
to the effects of the tension on the nervous system; that it
was, in fact, a nervous phenomenon. There can be no doubt
that several instances of elevation of teinjieratiu-e in children
and hysterical women after operation are in some way or other
reflex phenomena. Thus in a child the presence of a tight
stitch may be accompanied by a rise of temperature, which
subsides as soon as the offending cause is removed. Probably
this is the reason for the rise of tem])erature in Case 27, p. 472
(see fig. 79). In this case great difficulty was experienced in
keeping the u]>per fragment in position and there was therefore
FErEll DUE TO TEysIOX. 670
constant disturbance of the parts. At the same time, it must
be observed that the pulse rate had not increased in rapidity
in projjortion, and the patient did not feel out of sorts ; with
the exception of the elevated temperature there was no other
symptom of fever. Here there was no fermentation in the
wound and no retention of discharges, and therefore it seems
probable that it was a nervous phenomenon. On the other
hand, there are cases in which there may be great tension,
as after subcutaneous bruises, or local disturbance of the parts
as in some forms of joint disease, without an elevation of
temperature at all corresponding to that which occurs when
the discharges of wounds are retained. And also, the weight
of evidence derived from experiments on animals seems to go
against the view, that mere disturbance of the nerves of a
part is a frequent or probable cause of the marked elevation of
temperature which sometimes occurs in cases where there is
retention of discharge. Indeed, according to Wunderlich,^ the
application of external irritants has the effect of lowering the
general temperature rather than of raising it, and the same
author states that Heidenhain has found that iiTitation of
sensory nerves constantly and suddenly lowers the temperature,
except after division of the medulla oblongata from the spinal
cord or when fever is present. On the other hand, it has been
demonstrated that the products of inflammation (the serum of
pus, &c.), when introduced into a healthy animal, cause a rapid
rise of temperature, which soon passes off if no further injections
are made.^ It is thus quite possible, that when discharges are
retained by the blocking .of a drainage tube or for any other
reason, the fever which follows is due, at least in part, to absorp-
tion into the circulation of the retained materials. (In most
cases of elevation of temperature from tension the pulse is
' On Temperature in Diwase.
^ That the products of inflammation should cause fever is not surprising.
For, in inflammation, not only do liquor sanguinus and corpuscles pass out of
the blood-vessels, but the tissue cells, which are constantly taking material
from the blood and altering its constitution — in fact acting as ferments — are,
I think there can be no doubt, stimulated to increased activity; their func-
tion is also probably perverted, and the changes which they produce in the
nutritive materials with which they are supplied may be different from those
which occur in health, and may lead to the formation of substances which,
when absorbed into the circulation, cause fever.
p p 2
580 RESULTS OF ANTISEPTIC SURGERY.
correspondingly quick, and the patient feels ill — in fact, he
has fever. On the contrary, where it is a merely nervous
phenomenon, I think, though perhaps I may be hasty in this
conclusion, that the pulse does not increase in rapidity to a
corresponding degree.) This is, to my mind, the most pro-
bable explanation of the high temperature which occm's after
ovariotomy in Mr. Thornton's practice.^ Mr. Thornton does not
drain the peritoneal cavity, but stitches it closely up. The
consequence is, that the fluid effused from the divided pedicle
or from other injured parts is absorbed by the peritoneum, and
although ]Mr. Thornton's wounds are aseptic, yet he has fever
in many cases. This fever, however, is not fatal, for as the
pedicle heals the discharge diminishes and the temperature
falls. Here tension cannot be at work ; and further, surgeons
who di'ain the peritoneal cavity, and who at the same time treat
their cases thoroughly aseptically, do not meet with this high
temperature. Which of these two is the cause of the elevated
temperature in tension, or whether both may not play a part,
are questions which cannot as yet be definitively settled.
Though tension is the most important cause of elevation of
temperatm-e in aseptic cases, there are other minor causes, such
as retention of fgeces, the occm-rence of menstruation, &c.
What the meaning of the transitory rise of temperature after
aseptic operations is, it would be difficult to say. In some cases
no doubt, where much blood has been lost, it is merely the rise
which normally occurs in these circumstances. It seems to be
established in the case of the lower animals, that after blood-
letting, though the temperatm-e may fall in the first instance,
it generally rises to a considerably higher level than that at
which it stood before the blood was taken. Similar facts have
been observed after blood-letting in man. This rise of tempera-
tm-e after loss of blood is probably the explanation of the curve
in Case 16, p. 430 (see fig. 80). Here the ankle joint of a
hsemophilious child was opened and hemoi-rhage occurred from
the cut surface on various occasions diu-ing the following three
days ; there was no fermentation of the discharge and no
tension. Nevertheless loss of blood cannot always be the
cause, for what we may call the ' asej)tic curve ' occurs in
' Medico- CMrurgical Transactions, 1881.
TEMPERATURE IN CASES NOT TREATED ASEPTICALLY. 5S1
cases where little or no blood is lost. In aseptic cases it is
probably a nervous phenomenon, more especially as the pulse
rate in no way corresponds. I cannot discuss this matter
further, as much space would be required, and we do not yet
know enough about the origin and regulation of the tempera-
ture of the body. One fact is, however, apparent, that besides
the ordinarily recognised elevations of temperature after opera-
tions there is a transitory elevation tuhich occurs soon after the
operation and as an infiniediate result of it, and which can be
readily recognised when all other disturbing causes are excluded.
I have not met with any instance of the high temperature
which Volkmann has after a large proportion of Ids operations,
and which he has termed ' aseptic fever,' and I do not under-
stand it at all.
Fig. 82. — Temperature Chart from a Case where the Ankle Joint
was incised in a hyemophilious patient, and where hemorrhage
RECURRED SEVERAL TIMES (CASE 16, P. 430).
If one compares the temperature in cases which are treated
aseptically with that of those which are not, the contrast will
be found to be very marked. I do not of course by any
means intend to say, that the temperature is always high after
operations which are not treated aseptically ; far from it.
Many wounds not treated aseptically heal by first intention, and
in these there is, of course, no elevation of temperature or merely
the * aseptic curve.' Further, in many wounds in which fer-
mentation of the discharges occurs the discharge is drained
off and but little can be absorbed ; and in other cases the
wounds are small, or the conditions for absorption are not
favourable. In tliese instances there will often be no marked
elevation of temperature. But in a great numlier of severe
582 RESULTS OF ANTISETTIC SURGERY.
operations treated by the ordinary methods of cleanliness, as
described at p. 542, there is marked elevation of temperature —
traumatic fever — and in some cases this passes into a septicsemic
or pyaemic temperature. Look at the temperature chart of
Case 22, p. 434 (see fig. 81), and contrast it with that of Case
:rr
1
IITBIHM ^■■^■■^■■^i ^^ ^. ^j».*^i-M'-^ir»^Mr^j.^a»-t,^^^»
BB ^^BBWWBi^B^^B^^B^^B^^M^^B^^Bi^B^^B^^B^BiB^^BB>«ft wB^BBBI
11
Fig. 83.— Temperature Chart from the Case of removal op loose
Cartilage from the Knee-joint in which fermentation oc-
curred (see Case 22, p. 4;54).
15, p. 430 (see fig. 82). In the former case we have a small
operation performed on a joint, but fermentation occurred in
that joint. As a result we have a severe attack of fever.
(Here it is interesting to note that there was no ^putrefactive
7T
act.wfcii;iitg
jQQffij^QS^R^E^BEKQE^B
bbb:hii
wmmmmsm
Fig. 84.— Temperature Chart from a Cise op operation for recent
fracture of the Patella (Case 15, p. 4:?0).
fermentation.) In the latter case we have an operation of
greater severity, but the causes of fermentation were excluded,
and there is a correspondingly normal temperature. The
difference between aseptic and septic temperatures is also often
very marked after serious injuries or ojierations such as com-
TEMTEHATVliE IX SEPTIC CASES. 583
pound fractm-es. Contrast the temperatures in the cases of
compound fracture. In eight cases of compound fracture pro-
duced accidentally putrefaction occurred. In four of these
(Cases 14, 17, 20, 29) it is stated that the temperature ranged
for several days after the injury between 100° and 103° or even
higher. In one case (No. 4), though there is no statement as
to the temperature, there can be no doubt, from the description
of the case, that it was high. The temperatiu'e charts of three
cases are given here, and in two of them (Cases 12, 26) it
will be seen that traumatic fever was present, while in only one
(No. 40) was there a normal temj^erature. In one case (No.
58), in which putrefaction occurred after operation, amputa-
tion was jDerformed chiefly because the temperature was rising
rapidly ; and in another, of which the chart is given (Case 68,
Chart 35), there is little doubt but that some form of organism
got in, and here also we have a high temperature. Contrast these
with the highest temperatiires in cases of compound fracture
produced by the surgeon and treated aseptically. The differ-
ence is so marked that I need not dwell on it.^
If we contrast the, local and constitutional course of wounds
which are not kept aseptic with the foregoing description of
aseptic wounds, we see a very marked difference.
Look at the cases treated with antiseptics but not aseptically
in the foregoing tables. In one case of wound of joint (No. 3)
putrefaction was not avoided, and the case therefore became,
as I have previously pointed out, one treated with antiseptics
but not aseptically. Here fever and inflammation set in, and
threatened to be so serious in their results that it was considered
advisable to amputate. In one case of operation on a healthy
joint (No. 22) the wound was not kept aseptic, and thus the
case became one treated with antiseptics but not aseptically.
(It was dressed throughout with the ordinary gauze dressing,
' With regard to the temperature charts published in this work, I wish to
state that they have not been in any way selected ; I publish all the tempera-
ture charts which I have been able to obtain. Till 1877 temperature charts
were not in use in Mr. Lister's wards ; the temperatures were noted on a card,
and it was seldom that the clerk took the trouble to copy them into the books,
unless, indeed, the case was a serious one, and the temperature high. Hence
the average of the temperatures in the charts is probably higher tiian it ought
to be. *
584 RESULTS OF ANTISEPTIC SURGERY
XVIII
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TlOME'ERATUllE CJIAKTS UK SEPTIC CASES.
TEMPERATURE CHARTS OF ASEPTIC CASES. 585
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TK.MI'F.RATrUE ClIAUTS Ol' ASKI'TIC CasIO
o8G RESULTS OF ANTISEPTIC SURGERY.
and the spray and carbolic acid were employed with the view
of preventing the entrance of other mischievous particles.)
In this case inflammation and fever occurred. Contrast the
progress of these two cases treated with antiseptics with that of
the others which were treated aseptically. The same marked
difference will be seen if we look at compound fractures in
which fermentation was not avoided. The constitutional
results in these cases have been considered in a preceding
paragraph, while locally necrosis, inflammation, and suppuration
are recorded in several instances. I do not say that these
are the constant results in cases treated with antiseptics, but
they are the results in the series of severe operations which
we have been considering, and if they occur in these severe
operations there is no security whatever that they will be
absent from others which are less severe. That these results
often follow simpler wounds, will be evident from a perusal of
the foregoing chapters.
If, again, we take the open method, we find also a marked
contrast between the local and constitutional consequences of
wounds so treated and of those treated aseptically. Burow, as
we have seen at page 334, speaks of the great swelling of the
edges of the wounds, and Kronlein also tells us of the
inflammation and necrosis which so frequently occur. The pain
which must accompany this inflammation, and the exhaustion
produced by the prolonged suj)puration, are very marked features
of the open method. Kronlein,^ in his report of Eose's practice,
states that it was found best not to seek primary union after
amputations. He further states, that the first effect of the
wound is great swelling of the flaps, which goes on increasing
for some days, till, in fact, granulation is complete ; this is
inflammatory swelling. Kronlein also points out, that in
Burow's, or any other method in which the edges of the flaps
are brought together by stitches or plasters, the result of this
swelling is frequently gangrene of portions of the flaps. In-
deed, he says that in 58 cases of amputation treated by
the method before described (no attempt being made to bring
the flaps into contact) gangrene — not hospital gangrene —
occurred in six instances, or in 10*3 i)er cent of the cases,
' Luc. c'it.
PROGRESS OF WOUNDS UNDER OPEN TREATMENT. 587
simply as the result of the swelling of the flaps, combined in
one or two instances with injm-y to them. Kronlein also states
that necrosis of the end of the divided bone occurred very fi-e-
quently — in 19 out of the 58 cases, i.e. in 32*7 per cent. This
happens less often in the cases where the edges of the wound
are brought together, but Kj'onlein tries to make out that this
is chiefly because many of the patients in whom it would have
occurred die before it has time to take place. This explanation
is, however, to a great extent, incorrect ; for the true expla-
nation of the absence of necrosis in many cases where primary
union is aimed at is that primary union has occurred over the
bone, and hence the acute suppurative inflammation of the
bone due to the contact of irritating materials, which results in
acute necrosis, does not take place. The aseptic method, by
preventing this inflammation, renders it a matter of indifference,
from this point of view (the chance of necrosis), whether
primaiy union occurs or not.
Further, in cases treated by the open method there is
generally more or less fever, showing that absolution is occurring
from the wound in spite of the free escape of discharge, or
indicating the presence of inflammation in the wound. Kron-
lein does not enter into details on this subject, but he mentions
the fact, that in only six, or 8*7 per cent., of the amputation
wounds treated (67 in number) was there no rise of temperature ;
the temperature in these six cases hardly ever went above
100° F. This small proportion of cases in which there was no
fever contrasts markedly with the results after aseptic operations.
The open method also possesses other disadvantages which
make the contrast with the results of the aseptic method still
more marked. Thus there is a constant tendency to the for-
mation of crusts, which are apt to lead to retention of fluids and
their fermentation beneath the crust ; thus the wound loses
the advantages of the open method. Other disadvantages have
been previously alluded to.
The local results of treatment by irrigation and the water-
bath are also not so good as those after aseptic treatment, and
these methods possess several disadvantages. These disad-
vantages have been previously mentioned, and I need now only
allude to one or two. Thus the water is apt to run into the
588 RESULTS OF ANTISEPTIC SURGERY.
bed and wet the patient ; in order to avoid this, in the case
more especially of local baths, the apparatus must be so firmly
fixed to the limb that swelling is apt to occur. P'urther, the
maceration of the epidermis and the sodden state of the granu-
lations are great inconveniences. Also where the water used is
cold or where ice is too long ajDplied there is great danger of
gangrene in weak parts. Then, in the case of the water bath
more especially, where the wound is deep the swelling of the
granulations from imbibition of water is apt to block up the
orifice and confine the discharge ; and also pus coagulates
in contact with the water and frequently forms a thick layer
over the wound.
I need not dwell further on the points in which the other
forms of antiseptic surgery are inferior to the aseptic method.
Many of them are self-evident and have been already alluded
to. The results, both local and general, of all methods which
do not bring about an aseptic state of the wound are uncertain,
aind the results of these cases being uncertain the surgeon must
always have a feeling of anxiety corresponding in degree to the
severity of the operation and the interest which he takes in his
patient.
I have previously said, that on account of the various bene-
fits which are obtainable by the use of the aseptic method,
it ought to be employed wherever possible, unless, indeed,
special drawbacks attend its use. Several disadvantages,
to which I must now allude, have been attributed to this
method.
Firstly, it is said that there is a risk of carbolic acid poison-
ing. This, however, is not an objection against the method ;
it is an objection against the antiseptic employed, and is
equally valid when a wound is treated w^ith carbolic acid, though
not aseptically. Indeed, the risk of carbolic acid poisoning is
greater where wounds are not treated aseptically, for it is then
employed in large quantities to wash out the wound. Where the
aseptic method is carried out as formerly described, the wound
not being deluged with carbolic acid either at the time of the
operation or by injecting it afterwards, the risk of poisoning is
very slight. The occuiTence of dark coloured urine due to
CARBOLIC ACID POISONING. 589
absorption of carbolic acid is not very rare, but this is not
poisoning. Unless a remedy is taken in such quantities that
the patient's health or life are jeopardised by it, we do not say
that the patient has been poisoned. In the same way. unless
the absorption of carbolic acid has been so great as to produce
serious symptoms, we have no right to say that the patient is
suffering from carbolic acid jooisoning.
The subject of carbolic acid poisoning has been worked
out by Kuster, and Nussbaum,' who has had some experience
of it, has written a very interesting chapter on the subject.
According to them, carbolic acid kills by causing paralysis of
the respiratory centre. The heart continues to beat even after
the respiration is arrested, and the temperature also falls. In
severe cases all the symptoms of collapse are present, low tem-
perature, ' at first superficial and stertorous respiration, later
great pallor and, finally, sudden death by arrest of respiration.'
In less severe cases the following are the symptoms according
to Nussbaum : — ' They present at first gastric symptoms, which
must really be looked on as cerebral symptoms. These are loss
of appetite, frequent nausea or incessant vomiting ; there is
also an increase, often enormous, in the secretion of saliva,
which is very frothy. The urine diminishes in quantity ;
indeed, it has been said that it sometimes contains albumen,
but I have never observ^ed this.^ There may also be dysphagia,
immobility of the pupil, and the patient may have a certain
feeling of oppression or anxiety. The patients often lie abso-
lutely tranquil in their bed, as if they were prohibited from
moving, and they have difiSculty in spitting out the saliva
secreted. Fever is never absent till, in serious cases, the tem-
perature falls just before collapse sets in.' In addition to these
symptoms the urine on standing acquires a dark olive green
colour, though it may have been of normal apj)earance when it
was passed. This is due to the presence of indican.
The alleged presence of fever in cases of supposed carbolic
acid poisoning is a very puzzling circumstance ; for the evi-
dence derived from experiments on the lower animals does not,
' f.eitfddeti zur antisejJtischen Wvndhrhandlitvff. ]881.
* Dr. Keith stated, at the recent meeting of the International Medical
Congress, that the urine in some of his cases contained albumen.
590 RESULTS OF AXTISEPTIC SURGERl'.
so far as I am aware, lead to the conclusion that fever is one of
the results of poisoning with carbolic acid ; on the contrary,
it seems to be followed by depression of temperature. Under
the imjiression that fever was one of the symptoms of carbolic
acid poisoning, and wishing to produce fever in rabbits, I at
one time injected carbolic acid subcutaneously at frequent in-
tervals into a series of rabbits, but without obtaining the wished-
for result. So satisfied have some physicians become of the power
of lowering temperature possessed by carbolic acid that it has
been employed as an antipyretic in place of salicylate of soda.
These facts throw grave doubt on the view that elevation of
temperature is a symptom of carbolic acid poisoning, and lead
us to question whether many of the alleged cases of carbolic acid
poisoning are so in reality.
Many of the cases which have been published as cases of
carbolic acid poisoning are undoubtedly instances of septicaemia
occurring in patients who have been treated with spray, gauze,
and carbolic acid, but not by the Listerian method, i.e.
asejitically. In these cases there is a high temperature, and it
is said that carbolic acid has been found in the urine. The
temperature is often distinctly septicaemic in character, while
the presence of carbolic acid in the urine does not prove that
these are cases of carbolic acid poisoning. On the contrary,
Brieger,' who has investigated the subject of the formation and
excretion of carbolic acid in the living body, states that carbolic
acid is constantly present in the urine of septicsemic patients,
often in considerable quantities, even though no carbolic acid
has been brought in contact with them.
I do not wish to deny that this fever may be sometimes due
to carbolic acid, but, as far as I can judge, such a view is against
the evidence, though more facts are required before we can
come to a decision. That there is something different in the
result of administering carbolic acid internally and applying
it to a wound is evident from the fact which Nussbaum mentions,
that olive-colom-ed urine only occurs after the external use of
carbolic acid, and not when it is administered by the stomach
or inhaled into the lungs. Surgeons ought, however, to be
' ' Ueber Phenol-Ausscheidung bei Krankheiten,' Ccntralblatt f. d. Med.
Wissensck. 1878, No. 30.
TREATMENT OF CARBOLIC ACID ROISOXING. 591
very careful in attributing elevation of temperature in their
cases to carbolic acid poisoning.
In ]Mr. Lister's practice, and in that of many other surgeons
who use carbolic acid freely, but who operate aseptically, carbolic
acid poisoning is a thing of very rare occurrence, indeed I only
know of two cases treated by Mr. Lister in which serious
symptoms were present.^ The reason of this is that Mr. Lister
brings carbolic acid as little as possible in contact with .wounds,
but acts strictly in accordance with the aseptic principle, and
applies it freely to everything tvhich may come in contact luith
the ivound rather than to the wound itself. He does not irri-
gate wounds, nor inject them, nor even wash away the blood and
dirt from the line of incision. The surgeons who see the most
numerous examples of carbolic acid poisoning are those who,
led away by the dogmatic statements of eminent men to the
effect that the good results of Listerism are solely due to
cleanliness, apply this view to the treatment of their cases,
irrigating and washing wounds freely with carbolic acid, to the
great detriment of the wounds and the patients.
In the treatment of carbolic acid poisoning the first thing
is of course to remove the carbolic acid. This may be done
without at the same time abandoning the aseptic method. By
the use of eucalyptus gauze,'^ or by the use of salicylic or
iodoform di'essings, the patient may have the benefit of the
exclusion of organisms without the risks of poisoning. In
severe cases Nussbaum advises the subcutaneous injection of
three milligrammes of sulphate of atropia, which he says has a
beneficial effect on the vomiting and salivation ; he also advises
' In both of these cases there was elevation of temperature, bat it does not
necessarily follow that it was due to carbolic acid. The discussion of this
subject., and the speculations in which one might indulge with regard to it, are,
however, not suited for the present work.
* I have examined, by means of Koch's method of staining bacteria, a
number of wounds treated with eucalyptus gauze, and in a very considerable
proportion of them bacilli were found. I therefore cannot recommend the
eucalyptus dressings as being etjual to those with carbolic acid. As we have
already seen, micro-organisms are not found in wounds treated with carbolic
acid, or, if present, they are only micrococci. I have not found bacilli under
carbolic dressings. On the contrary, with eucalyptus oil, though sometimes
no organisms are present, yet in a considerable number of cases bacilli may
be found ; micrococci are but seldom seen.
5JJ2 RESULTS OF ANTISEPTIC SURGERY.
that the patient should be packed. Where collapse is present
Nussbaum has derived benefit from the use of the following
means : friction of the chest, of the hands, and of the soles
of the feet with a brush, and the subcutaneous injection of
ether and camphor. In milder cases, besides the removal of
the carbolic dressings, he advises the use of sulj)hate of soda as
follows : —
Sulphate of Soda o parts.
Distilled Water 100 parts.
Syrup of Raspberries .... 25 parts.
Two tablespoonfuls of this mixture are given every two hours.
This method of treatment was proposed by Baumann, who found
that carbolic acid was not excreted by the kidneys as carbolic acid,
but in the form of a non-poisonous compound with sulphuric
acid. It is with the view of obtaining this non-poisonous
compound that the sulphate of soda is administered. It is
said not to do much good. I have myself had no experience
of it.
The so-called ' carbolic eczema ' has been brought forward
by some writers. I have already referred to it, and mentioned
the use of salicylic acid cream as a preventive. It has been
attributed alternately to carbolic acid, to the paraffin and to
the resin in the gauze, but as I have already exj)lained, it seems
to me in some cases more probably due to a fermentation of
the discharges caused by micrococci (see p. 232).
In tw^o cases I have known a carbolic acid dressing blister
the skin in a few hours and have to be abandoned. Here,
however, as I have before said, it was merely carbolic acid, not
the aseptic method, which was abandoned ; another antiseptic
was used in its stead.
Another argument has been brought forward against the
aseptic method, viz., that it distracts the attention of the
surgeon from the constitutional state of his patient. Such an
argument has no foundation in fact. Are the precautions
necessary to attain the single object of the exclusion of micro-
organisms from wounds more likely to divert the surgeon's
attention from the constitutional state of his patient than the
numerous cares as to ventilation, nursing, and so forth, with
which the surgeon who trusts to cleanliness alone is harassed ?
EXPENSE OF ASEPTIC TREATMENT. 693
In the great majority of simple fractures no attention is paid to
the constitutional state of the patient ; the limb is placed in
splints, full diet is ordered, and the patient is left till the bones
unite. Why is it thought necessary to attend to the constitution
of the patient when the bone is divided by an incision through
the skin ? Because under ordinary circumstances inflammation,
suppuration, fever, and other hurtful consequences are apt to
occur. But, as we have seen, the aseptic method avoids all
these dangers and makes the wound practically subcutaneous.
Where, then, is the necessity for attending to the constitution
more than in the case of simple fracture ? ^ But fm'ther, as
Mr. Lister himself has pointed out, such an argument is of no
weight in presence of the facts ; for, if Mr. Lister gets such
avowedly good results (better than those obtained by surgeons
who jjay great attention also to the constitution), and at the
same time, as is however wrongly alleged, neglects the con-
stitutional state of his patients, such a fact would be an
additional argument in favour of aseptic treatment, and only
prove the great efficiency of the method.
Then it is said that the method is costly, and therefore
not applicable in the case of poor patients. Now no doubt
each individual dressing is costly — costing at the most \Qd. or
Is., though generally much less — but then these dressings, after
the first two or three days, require to be changed only at rare
intervals, and I have calculated that in most cases, with of
course some exceptions, the dressings are really in the long run
cheaper than water dressing changed once or twice daily. But
further, the aseptic method saves expense in many other ways.
As the patient has no pain nor fever, it is only in a few cases
that a trained nurse is required ; any sensible friend or servant
can attend him quite well. And as he is not suffering fi'om
fever nor weakened by profuse discharges, he fre(]uently does
not require stimulants or tonics, indeed in Mr. Lister's practice
these are seldom ordered ; this advantage is no doubt to some
' It must not be supposed from this that I would advise the neglect of the
constitutional state of the patient. On the contrary, every care ought to be
taken to attend to hj'ij^ienic conditions, and by means of good diet to support
his strength, or by suitable drugs to attempt to remedy any constitutional
defects.
Q Q
594 RESULTS OF ANTISEPTIC SURGERY.
extent counteracted by the fact that the patient has an excel-
lent appetite. Further, wounds heal on an average more quickly
than when treated by the ordinary methods, and as the patient
is not weakened by the presence of fever or discharge, the
period of convalescence is shorter. This is, of coru-se, of the
greatest importance to the bread-winner, for he is well and
back at his work while the patient who has not been treated
aseptically, and whose wound has not united by first intention,
is still undergoing treatment or recruiting his powers in the
country. Thus in numerous ways, of which these are a few
examples, ex[^ense is saved, and on the whole this treatment
is from this point of view the one most applicable to poor
patients.
Lastly, it has been said that the aseptic method gives the
surgeon a great deal of trouble. Now there is no doubt that
at first each operation and each dressing requires care and
thought, but then the dressings are unfrequent, and by-and-bye
the method becomes more or less instinctive. This argument
of trouble could not, however, be seriously upheld for a
moment, for if a system is good it must be carried out in spite
of the trouble involved. Why does one take so much trouble
in perfecting one's anatomical, physiological, or practical know-
ledge but simply with the view of being able to treat his
patients better ? For the same reason the trouble ought to be
ungrudgingly expended here. And if there were no other
reason (such as the safety and well-doing of the patient), the
relief from anxiety on the part of the surgeon, and the feeling
of certainty as to the result, are of themselves a sufficient
reward for all the trouble bestowed. The chief point which is
laid stress on as giving rise to increased trouble is the use of
the spray. I have already discussed this question at pp. 73,
120, and 364, and I have also pointed out the methods by
which treatment without the spray may be carried out. As 1
have said, the spray is the least necessary of all the precau-
tions, because fewer micro-organisms are present in the air
than on surrounding objects, and, therefore, the purification of
the air is the least important : further, if any particles do fall
on the wound from the air, they may be readily destroyed by
washing the surface of Ihe wound with an antiseptic lotion.
PRAY NOT ESSENTIAL FOR ASEPTIC TREATMENT. 595
I have already pointed out that the spray can be dispensed
with, and that operations can be performed without it ; it can-
not, however, be safely abandoned without a substitute being
provided m the shape of frequent irrigation of the wound. In
proof that aseptic surgery may be carried on without the spiay,
we have Mr. Lister's work of several years — and very successful
work it was too — before he introduced the spray ; but then
while he performed the operation he constantly poured carbolic
oil or carbolic lotion into the wound, and in dressing the case
he had a current of the oil or lotion flowing over the wound.
Then further, we have Mr. Callender's experience. He prac-
tically employed,' with some modifications, Mr. Lister's original
method with carbolic oil, and his results were good. And,
in 1879, Trendelenburg ^ published the results which he had
obtained without the use of the spray. He employed the
method of continually irrigating the wound with carbolic lotion
while he performed the operation and while he dressed the
wound. And his results are, in the main, as indeed was only
to be expected, aseptic results. He mentions eighteen cases
where hydroceles were opened and successfully drained ; eight
cases where the sheaths of tendons or ganglia were opened
without local reaction ; twelve cases in which joints were
opened, in only one of which was there inflammation; and
five osteotomies, of which one died of tetanus, the others
doing well. The spray, however, has advantages which seem
to me far to outweigh its disadvantages. In the first place, I
think it is really less trouble to have a spray playing over a
part than to be continually irrigating it with carbolic lotion.
Further, there is a feeling of certainty attending an operation
conducted under the spray (see p. 259;, for if no s^miy is used
septic particles may fall into the wound and escape the action
of the lotion ; this is most likely to be the case while the
wound is being stitched uj), and these particles may be })ro-
tected by the blood clot from the action of tlie carbolic acid,
and may not be destroyed by the clot or the living tissues,
but may develop and cause fermentation in the wound. Lastly,
the spray has this great advantage over irrigation, that less
cai'bolic acid is applied to the wound, and thus there is less
' Lnc. rit.
596 RESULTS OF ANTISEPTIC SURGERY.
irritation of the cut surface and less chance of absoiption of
carboHc acid into the system. It cannot be a good thing
either for the patient or for the wound to be constantly
deluging it with strong carbolic lotion.
The whole principles of wound treatment may be summed
up in the one word — Rest. This has been urged by many
writers, from Magatus downwards, and indeed before the time
of Magatus ; but it is only within the last few years that science
has so far advanced as to enable us to grasp the whole signifi-
cance of that term as applied to the treatment of wounds.
The causes of Unrest may be mechanical or* chemical.' The
mechanical causes consist of movement of the parts, of the
presence of foreign bodies, of tension in the wound, and so on ;
and they are, as a rule, easily avoided by the use of suitable
apparatus, by the removal of mechanical irritants, or by providing
against the occurrence of tension ; and inasmuch as they are
easily avoided they are comparatively unimportant. The most
importa;nt and the least easily prevented are the chemical causes
of Unrest, and these may be divided into two great classes :
1. Where the chemical substance is merely something — a salt,
or an acid, or an alkali — added to the wound from without,
such as carbolic acid. Such a chemical cause will act only in
proportion to the amount added, to its irritating property, and
to the length of time that it remains in contact with the surface
of the wound. When the original quantity is exhausted the
' IMr. Lister long ago divided the causes of supjjuration into three great
groups : 1. Putrefactive suppuration where it was due to the presence of
putrid materials; 2. Antiseptic suppuration where it was due to the presence
of some chemical substance, such as the antiseptic employed in the treatment
of the wound ; 3. Suppuration the result of nervous disturbance, as intension.
This classification still, I think, holds good, notwithstanding the recent work
of Dr. Ogston referred to at pp. 248, 251), who has expressed the opinion that
all acute abscesses are due to micro-organisms. The observations which I
liave published at p. 251, and others which I brought forward at the recent
meeting of the International Medical Congress, seem to me to go against this
view. At the Congress Mr. Lister also pointed out a number of clinical facts
which proved that other causes of acute inflammation and suppuration exist
besides the action of micro-organisms. I do not, of course, deny that micro-
organisms are the cause of many of the acute absce.sses in winch they are
found, but I think that in some they are accidental, and that suppuration
may be induced othervvise than liy their action.
REST, THE PRINCIPLE OF WOUND TREATMENT. 597
chemical irritation ceases. 2. The other cause of chemical
Unrest is where the chemical substance is being constantly
formed in the wound. Here we have much the most formidable
cause to deal with, for there is no exhaustion of the substance,
but, on the contrary, continued formation of fresh material so
long as the causes of this formation are present in the wound ;
and, as we have seen, the eradication of these causes, once they
have entered, is a very difficult matter, and thus these causes
of Unrest are the most important. To interfere with these
causes of Unrest is the main object of antiseptic surgery. The
prevention of their entrance is the special aim of aseptic treat-
ment. The prevention of the entrance of micro-organisms is,
as we have already seen, apparently much more easily and
better accomplished than their destruction after they have
entered. And further, in attempting their destruction after
their admission, the wound is subjected in a marked degree to
chemical Unrest of the first class. The ideal wound is a sub-
cutaneous one, kept at perfect rest. We have not yet attained
this ideal, for even with the aseptic method there is a certain
amount of Unrest caused by the antiseptic employed, by the
stitches, by the apparatus for drainage, and by the dressing
itself. Nevertheless, the essential elements of Unrest have
been abolished by this method, and the disturbances from the
antiseptic, from the stitches, and so forth, have been reduced to
a minimum, and now hardly make themselves evident. That
art will still fm-ther perfect the treatment of wounds there can
be no doubt ; but whatever development occurs in the future, the
great principles of Listerism, the exclusion of the chief causes
of chemical Unrest, and the reduction of the action of the other
causes to a minimum, must form the groundwork of any system.
In conclusion, I cannot too strongly express my conviction
that the scientific basis of wound treatment should hold the
most prominent place, and that it is only by a thorough know-
ledge of natural phenomena in all their bearings that the best
practice can be carried out and the best results obtained.
Loose observations and loose and vague ideas as to probabilities
wliich have no foundation on the facts of nature, cannot
advance art in any way. Natural phenomena are generally
found to differ from the conception which man in his ignorance
598 EESULTS OF ANTISEPTIC SUIIGERY.
is apt to form of them ; and therefore any statements on any
subject, to be of value in the development of that subject,
must be founded on knowledge and rigid application of the
facts of nature, whether or no these facts seemed at first sight
probable or sufficient explanation of the phenomena. That
advance can only be blind and imperfect till the true law of
nature is discovered is well illustrated by the history of wound
treatment in former years. Through the darkness which then
reigned glimmers of light had at times penetrated, but no
true and lasting progress was made till quite recently, when,
chiefly by the scientific labours of two men — Pasteur and
Lister — a flood of light has been thrown on one of the most
obscure subjects in nature, and the foundation of rational
methods of treatment on rational and scientific principles has
been followed by inestimable advantages to mankind.
Plaiel
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EXPLANATION OF THE PLATES.
These sjjccimens have been drawn by the aid of the Camera Lvcida, and Zeii^
water-itmnersion or oil-immersion lenses were those chiejiij emjdoyed.
PLATE I.
PIG. PAGE
1. Micrococci, from a wound treated aseptically, growing in infusion
, of cucumber. x 14.50 ......... 231
2. Specimen of discharge taken from a case of compound dislocation
of the tliumb not treated aseptically. Contains numerous micro-
organisms. X 1450 235
3. ISpecimen of the discharge from a case of wound of the scrotum not
treated aseptically. Contains numerous micro-organisms, x 1450 235
4 Discharge from a case not treated aseptically. Bacilli and pus
cells. X 1450 235
5. Discharge from a case of amputation treated by irrigation. Red
blood corpuscles, leucocytes, a few bacilli, x 1450 . . . 235
6 Discharge from a case of excision of the hip-joint treated with anti-
septics. Micro-organisms and blood-corpuscles, x 1450 . . 235
7. Discharge from a case of Syme's amputation treated with antiseptics.
Pus corpuscles and micro-organisms, x 1030 .... 236
8. Discharge from a case of empyema treated aseptically. Leucocytes :
no micro-organisms, x 1030 ....... 237
PLATE II.
9. Discharge from a case of empyema treated aseptically ; taken at a
later period than that in the specimen from which fig. 8 was
drawn. No micro-organisms, x 1030 ..... 237
10. Discharge from a case in which a diseased knee-joint was incised
aseptically. No micro-organisms, x 1030 238
11, 12, 13, and 14 are from specimens taken at different times from a
case treated aseptically. The first three specimens are free from
micro-organisms ; the last contains micrococci, x 790 . . 239
600 EXPLANATION OF THE PLATES.
FIO. PAGE
15 and 16. Taken from a case of excision of tlie mamma treated with
aseptic precautions. Fig. 15 contains no micro-organism.s. x 790.
Pig. 16 contains numerous micrococci, x 550 .... 210
PLATE III.
17. Specimen from a case of operation performed with aseptic precau-
tions. Contains a few micrococci, x 10.30 240
18, 19, and 20. Specimens to illustrate the mode of entrance of micro-
cocci into wounds treated aseptically. Fig. 18 sliows discharge
talcen from the drainage tube on March 31. No micro-organisras.
X 790. Fig. 19 shows discharge taken from the edge of the
dressing on April 4. Micro-organisms are present x 1030. Fig.
20, taken from drainage tube on April 4, contains no micro-organ-
isms. X 1030 241
21, 22, 23, and 24, illustrate the same point. Fig. 21, taken from the
gauge on April 4, contains a few micrococci. Fig. 22 taken from
the inner drainage tube on April 5, contains no micro-organisms.
Fig. 23, taken from the inner drainage tube on April 8, contains
one or two micrococci. Fig. 24, taken from an outer drainage
tube leading into an abscess cavitj'', on April 15, contains no
organisms. Figs. 21, 23, and 24 al30 illustrate the fact that the
leucocytes found in exudations from wounds treated aseptically,
frequently do not appear as healthy pus cells, but seem to be de-
generating, ot, if derived from the tissue corpuscles, perliaps to
have been imperfectly developed. All the specimens are x 1030 2*42
PLATE IV.
25. Growth of micrococci as observed under the microscope by Mr.
Lister, a. Group at 855 a.m. b. Same group at 9-4 a.m.
c. Same at 9-30 a.m. d. Same at 1036 a.m 244
26, 27,'and 28 represent micrococci growing in various materials. Fig.
26, discharge from the wound from which the micrococci were
taken, x 600. Fig. 27, the same micrococci growing in vitreous
humour, x 1030. Fig 28, the same growing in cucumber infusion
after having previously lived in meat infusion, x 1030 . . 245
29. Pus taken from a chronic abscess, contains no micro-organisms.
X 1030 254
30. Pus taken from an acute abscess of the mamma when opened, con-
tains micrococci, x 1030 ........ 254
31. Pus taken from an acute abscess of the finger, contains micrococci.
X 1030 254
32. Pus taken from an acute abscess of the groin when opened, contains
streptococci, x 1030 256
EXPLANATION OF THE PLATES. 601
PLATE V.
FIO. PAGE
33 to 38 were kiiKlly examined for me by Mr. E. Nelson, whose skill in
microscopical work, and more especially in the uses of illumina-
tion, is so well known. These specimens have been drawn from
his microscoiDe.
33. Specimens of milk which had been preserved without boiling for
several months. Contains no organisms ..... 41
3i. Specimen of the deposit in a beaker containing cucumber infusion,
into which the spleen of an animal had been drojaped some days
previously. No micro-organisms ....... 4G
35. Specimen of dust collected and stained with meth}-! violet. One or
two bodies are present which are indistinguishable from micro-
cocci and bacteria, and have taken up the stain . . . .198
36. Specimen of discharge taken on April 13, from a case of removal
of loose cartilage from the knee-joint in whicli supjiuration
occurred. Contains oval organisms ...... 454
37. Specimen of discharge taken on April 18, from the same case . . 455
38. Discharge taken on April 22, from the same ..... 45G
9. Piece of liver introduced into the abdominal cavity with aseptic
precautions, examined 24-48 hours later. Leucocytes have jsene-
trated between the lobules of the liver, and at the upper part of
the figure have already become spindle-shaped (Hartnack 2 eye-
piece, 7 objective). From Tillmanns ...... 575
40. Piece of dead liver after 17 days in the abdomen; organisation of the
leucocytes into fibrous tissue, vessels, &c. (Hartnack, 2 eyepiece,
7 objective). From Tillmanns . . . . . . . 575
INDEX,
ABD
4 BDOMEN, wounds of, aseptic treat-
1\. ment, 115
Aberncthy on treatment of wounds,
306
Abiogenesis, theories of, 145
Abscesses, acute micro-organisms in,
25H
— significance of micrococci in, 255
— Anel on aspiration of, 300
— aseptic drainage of, 110
-- aseptic treatment of, 109
— chronic, effects of air on, Aheriuttky
on, 30G
B. Bell on, 306
^1. Mniiru on, 30(>
H. Mnnru on, 306
— relation of micro-organisms to, 253
— treatment of, Pearson on, 312
• Bidder on, 303
— lumbar. See Lumbiir abscess.
— near anus, aseptic treatment of, 112
— near pubis, dressing of, 105
— of hip-joint. See Hip-joint.
— of joints, aseptic treatment of, 443
— perineal, aseptic treatment of, 1 1 2
— psoas. See Psoas absce-ss.
— retropliaryngeal, aseptic treatment
of, 110
— spinal, recumbent position in, 1 1 1
— thoracic. See Empyema.
— valvular, treatment of, Ahernetlni on,
307
— vertebral, absence of statistics of,
530
— — aseptic course of, 51'.), 5.18
pathology of, 555
results of, 517
time for opening of, 51 'J
Absorption by granulations, Ilavli on,
268, 26;», 407
Adams on subcutaneous surgery, 321,
322
ANT
Air, effects of, on wounds, Ahernethj
on, 306
Benjamin, Bell on, 305
Jolm Bell on, 310
Demarqnay and Lecontr
on, 331
■ Humphrey on, 334
• John Hunter on, 308
Malgaigne on, 331
■ ~ Ale.v. Munro on, 306
■ Hugh Munro on, 306
— Pringle on, 305
• Vali'tte on, 345
-^ Veljjeav on, 331
— ~ examination by the Author, 198
Pasteur, 165
Pouchet, 163
— filtration of, through cotton-wool,
12
— &A«vf//«'.vexperimentswithheated, 6
Albert on operation on joints, 447
Albuminuria, operations in, 559
Alcohol as an antiseptic, 269, 348
— results of treatment with, 40G
Alcoholic fermentation, 209
Alumina, acetate of, use in aseptic
treatment, 139, 363
Amputation in phthisis, 559
AniMsmt on irrigation, 341
Anal abscess, aseptic tre;itment of, 112
Anel on aspiration of aV)sccsses, 300
Animal tissues boiled, fermentation of,
14,22,24
unboiled, fermentation of, 45
Antiseptic, definition of term, 1
— derivation of term, 1
■ — surgery, history of, 290
in sixteenth century, 292
seventc(!nt h cent ur3% 29G
eighteenth century, 300
• present centurj', 317
meaning of term, 1, 145, 265
G04
INDEX.
ANT
Antiseptic siirgeiy, points in testing-
result, 367
principles of, 288
relations to fermentations in
wounds, 366
relations to infective disease, 540
results of, 365
summary of views on, up to 1800,
314
varieties of, 265
Antiseptics, Beiinion on use of, 336
— Bilguer on use of, 302
— Colhatch on use of, 297
— in common use, 348 et seq.
— treatment by, 265, 267, 583
history of, 347
Lister s results in, 376
■ relation to fermentation
in wounds, 366
relation to infective disease, 405
Rei/hersi results in, 401
Ajyjjerfs method of preserving fruits,
&c., 4
milk, 15
Arncpus's method of wound treatment,
294
Aryicmann, treatment of wounds, 312
Aseptic cases, table of temi:)erature
charts of, 585
Aseptic coiirse of chronic abscesses,
519, 638, 555
compound fractures, 462, 563
operations on joints, 421
wounds, outline of, 566, 575
Aseptic method, does it exclude micro-
organisms from wounds ? 227, 454
does it prevent fermentations in
wounds ? 226, 366
Aseptic operations, diet after, 576
duties of dresser in, 72
errors in, how corrected, 74
example of, 67
ligature of vessels in, 75
on joints, results, 426
temperature after, 576
use of carbolised towel in, 67, 72
use of guard in, 74
Aseptic surgery, definition of, 51
general results of. See Statistics.
principles of, 51, 52, 359
relations to infective disease, 368,
540
Aseptic temperature curve, 580
Aseptic treat mcnt, advantages iDCCuliar
to, 561
bearing on conservative surgery,
562
AUT
Aseptic treatment, cost of, 593
development of, 128
example of failure of, 454
experience essential in, 504
in country practice, 120
in war, 123
objections to, 588
of abscess, 109
accidental wounds, 112
bursitis, 568
burns, 117
compound fractures, 114, 461,
563
of skull, 1 1 5
contused wounds, 113
dissection wound, 119
gangrene, 117
— gunshot wounds, 123
— hydrocele, 568
wounds of abdomen, 115
intestines, 115
— joints, 1 14
results, 422
muscles, 114
nerves, 114
tendons, 114
thorax, 115
relation to erysipelas, 541
trouble connected with, 594
use of acetate of alumina in, 139
— eucalyptus oil in, 140
thymol in, 139
salicylic acid in, 136
Aseptic wounds, AvfJuir on micro-
organisms in, 229
drainage of, 76
micrococci in, 243, 256
stitching of, 85
strapping of, 86
substitutes for carbolic acid, 136
Aseptic use of cotton wool, 141
salicylic acid, results of, 404
thymol, results of, 404
Avtlior, examination of air, 198
— experiments on destruction of bac-
teria by healthy tissues, 252, 283
— experiments on fermentation, 25
of blood, 36
micro-organisms in aseptic
wounds, 229
relation to living body,
205 et seq.
spontaneous generation, 193,
195, 200, 202
— on fermentation of boiled urine, 25
— unboiled animal tissues, 45
egg albumen, 43
INDEX.
C()5
AUT
A^Mor, on fermentation of unboiled
milii, 3'J
— urine, 37
Axilla, aseptic dressing of, 100
BACILLI in wounds treated with
eucalj'ptus gauge, 591
Bacteria, formation of pigment by, 212
— Koch's method of staining, 233
— under A. Guerin's dressing, 329, 330
Bandage, carbolic gauze, 89
— elastic, 90
— muslin, 89
Bandaging of gauze dressing, 89
Bardelchen on Listerism, 361
JBardenheuer, results with aseptic treat-
ment, 416
— statistics of compound fractures, 509
Jjarher on use of cotton wool, 143
Barnes on results of cleanliness, 548
Barth's statistics of wounds of joints,
445
Burtschcr and Vfziii's ojDcn method of
treatment, 277, 332
Bastiaii on spontaneous generation,
176, 181, 187, 191, 196
BataiUe. on dressings with alcohol, 348
Bell, Benjamin, on action of air on
wounds, 305
— — on drainage tubes, 305
— • — on wound treatment, 304
Brll, Sir ('., on removal of loose carti-
lages, 3 1 2
subcutaneous division of liga-
ments, 319
Bell, John, on effects of air on wounds,
310
treatment of com[H)un(l frac-
tures, 31 1
wounds of joints, 31 1
_ . vvound treatment, 312
Bclloste on treatment of wounds, 300
Jienfiion on wound treatment, 336
Jifrard on irrigation, 339
Benimunn ongunstiot woimds of joints.
452
Jicrt on fermentation, 220
— — spontaneous generation, 184, 185,
201
BiUjuer on results of con]i)ound frac-
tures, 302
— — wound treatment, :i02
Billruth on micro-organisms, 243
in abscesses, 253
— statistics of sej)tic treatnuiil, 41i)
Billroih and Tiiyel on fermentation of
unboiled animal tissues, 44
lUstournage, 249
Blanchurd on A. Guerin's-dressing, 326
Blondiis on treatment of wounds, 292
lUood, fermentation of, 33
Blood clot, organisation of, 568
Boerhaave on putrefaction of pus, 301
Boiled substances, fermentation of, 1,
29
Bone, gunshot wounds of, results of,
512
— organisation of, 571
Bon net on. cauterisation of wounds, 338,
349
Boracic acid lint, 64
lotion, 64
ointment, 64
-— lint dressings, changing of, 94
use of, 93, 268
wet, in place of poultice, 95
— ointment as a dressing, 94
Bouisson's method of ventilating
wounds, 279, 337
Boi/er on treatment of wounds, 314
Brodie, B., on treatment of varicose
veins, 319
Brims on carbolic acid gauze, 63, 362
treatment of wounds, 291
Bryant on Lister's operations on joints,
440
Buff on on spontaneous generation, 147
Burdo a- Sanderson on fermentation of
blood, 35
unboiled animal tissues,
45
micro-organisms in living
body, 250
— sjionlaneous generation, 188
liurns, asejitic treatment of, 117
Biiron-, open method of treatment, 278
- on results of the open method, 333,
409
liursitis, aseptic treatment of, 568
Jiussji on use of coal tar, 351
Button stitches, 85
Butyric fermentation, 2J2
r^AIiOT^m elilniiiialcl soila, 269
^ Cmiinttrd- Liitimr nn yeast cell.s, 6
Cullender's method nf woiukI treatment ,
363, 595
Ciilrert on carbolic; acid, 352
Cameron's statisti(;s, 371
Camjiioiii. on crust formation, 338, 349
Carbolic acid, Lema'irc on use of, ;{54
606
IXDEX.
Carbolic acid, oily solutions of, 5o
poisoning, 588 ct seq.
solution of, in glycerine, 54
substitutes for, 136
• undiluted, 53
use in treatment by antiseptics,
267
watery solutions of, 53
— eczema, 232
Carbonic acid gas, treatment by, 330
Cartilages, loose, removal of, B. Bell on,
305
<^r C. Bell on, 312
Sam. Cooper on, 312
Chassai(i)w on, 321
Gibson on, 313
— Larrey on, 45!)
Levdllc on, 313
Spencc on, 460
'llu-dcn on, 308
Catalysis, 2
Catgut carbolised, 56
chromic (Lister's), 57
— chromic (MacE wen's), 58
— drainage by, 80
— Lister's pocket-holder, 5"J
— organisation in, 571
— trough for, 51)
— use as a ligature, 75
Cazeiieuve and Li con on fermentation,
218
— of unboiled urine, 37
on spontaneous generation,
l'J5, 201
Chalvet on use of lime chloride, 349
Championn'iire on results of aseptic
treatment, 3!)8
Cliasmi/inac on occlusion, 323
Chassaigne on subcutaneous surgery,
321
Climdiae, Gnij dc, on treatment of
wounds, 2!)1
Chnuveau on bistournage, 24!)
llii-dererqne on dressings with alcohol,
348, 406
Clieniical fermentation, 2
(lievrcul on use of coal tar, 351
Chienc on catgut drains, 80, 362
retropharyngeal abscess, 110
situation of opening in jisoas
abscess, 102, 518
— and Ewart on fermentation of un-
boiled animal tissues, 49
Chlorinated soda as an antiseptic, 26!)
f 'Iilorine as an smtiseptic, 34!)
Chivicle, compound fractures of. See
Compound fractures.
CON
Cleardiness, definition of, 542
— McVaiFs results with, 415
— Nussbaum's results with, 390, 394
— results of, 544 et seq.
— Savory's results with, 414
— treatment l)y, 542
— value of, 546
— Volkmann's results with, 385, 405
Coal tar. Come and Demeaux on, 350
Lcmaire on, 350
Colin on pigment bacteria, 212
spontaneous generation, 179
ColhatclCs method of wound treatment,
297
Cold in wound treatment. See History
of Irrigation.
Collodion, nse of, 324
Compound fractures, accidental, general
aseptic results, 510
aseptic course of, 462
treatment of, 114, 461, 563
J. Bell on, 311
eradication of putrefaction in,
478
intentional, general aseptic re-
sults, 511
Lister's, summary of, 484, 498
made by surgeon, 464
of clavicle (surgeon), 494
femur (accidental), table of,
466
(surgeon), table of, 484
forearm (accidental), table of,
476
(surgeon), table of, 496
humerus (accidental), table of,
474
(surgeon), table of, 494
of leg (accidental), table of
464
— (surgeon), table of, 490
limbs (accidental), summary of,
478
lower jaw (surgeon), summary of,
498
Pott's results in, 304
results of asejjtic treatment of,
461
— Bilguer in, 303
open method, 514
of skull (accidental), summary of,
478
aseptic treatment of, 1 15
Condensed beam of liglit, use of, by
Prof. Tyndall, 17
Conservative surgery, bearing of aseptic
treatment on, 562
INDEX.
607
CON
Constitutional state after aseptic opera-
tion, u75
Contused wounds, aseptic treatment of,
113
Coolie, Jas., on danger of joint wounds,
2;)6
Cooper, Sir Astleij, on subcutaneous
tenotomy, 319
wound treatment, 313
Cooper, Bransiij, on subcutaneous teno-
tomy, 319
Cooper, Sam., on removal of loose carti-
lages, 312
Come and Deineaux's powder, 351
Cost of aseptic treatment, 593
Cotton wool, aseptic use of, 141
carbolised, 66
A. Guerin's dressing, 280, 325, 408
Country practice, aseptic treatment in,
120
— — mode of dressing in, 122
Croft on results of cleanliness, 549
Crust, formation of, 335
Bouisson on, 279, 337
Fallopius on, 294
J. Hunter on, 310, 335
Neudorfer on, 271, 279, 335
treatment by, 279
Czerny on results of aseptic treat-
ment, 398
J^iUJLAT on use of carbolic acid, 355
J-^ Delacroix on treatment of wo und s ,
293
Deleaic on perchloride of iron, 350
Delpcch on subcutaneous tenotomy, 319
JJemarquay on micro-organisms in
wounds, 228
— on treatment by glycerine, 348
— and Lecontc on carbonic acid gas,
331
Demeaux and Corne's powder, 351
iJesinazieres on yeast, 6
JJU'ffenbacli on subcutaneous surgery,
320
Diet after aseptic operations, 570
Dissection wound, aseptic treatment of,
119
Drain, catgut, 80
— ■ horse-hair, 82
■ reiutroduction of, 83
Drains absorbable, 80
Drainage as an antiseptic method, 271
- aseptic, of abscess, 1 10
— by capillarit}', 80
— of aseptic wounds, 7(J
EGG
Drainage tubes absorbable, 83
— B. Bell on, 305
— position of tube in aseptic wotinds,
78
— ttse of, 76, 458
Bran, Le, on putrefaction of pus, 301
Dresser, duties of, in aseptic operation,
72
Dressing, aseptic, axillary, 100
boracic, 93
of breast (3 methods), 97
changing of, 94
deep, 68, 88
errors in use of protective, 87
excisions of joints, 107
fixing of, 89
general gauze, 89
of hernia, 105
hip- joint abscess, 104
limbs, 101
loose gauze in, 89
of lumbar abscess, 104
method of clianging, 91
of neck, 96
ovariotomy, 109
psoas abscess, 101
scalp, 96
scrotum, 105
time of changing, 93
use of pins iir, 89
use of protective in, 87
wet gauze in, 88
— water, 292, 315
Dressings, aseptic, in country practice,
122
permanent, Keuher on, 362
-— — use of sponges in, 122
with salicylic acid, 136
Dumas on carbolic acid, 352
Duncan, Matthcics, on saprjemia, 367
Dupuytrcn on subcutaneous myotomy,
319
Duroij on use of iodine, 350
Duscli and Schroeder on fermentation,
12
of boiled animal tissues,
14
milk. 1 4
• " spontaneous generation,
152
I^X'ZKMA, carbolic, 232, 592
J Egg albumen, boileil, llohirts 'm
ferment al ion of, 22
- Schrneder on fermentation of, II,
15
608
INDEX.
EGO
Egg allmmen, unboiled, fermentatidn
of, 42
Egineta, Paul d\ on healing of wounds,
291
Empyema, aseptic treatment of, 111
E)icyclopcdie MHho/Uqne on purity of
air, 306
Eremacai;sis, definition of, 9
Enchsen on niortalitA* after amputation,
4U
Errors in aseptic operations, how cor-
rected, 74
Erysipelas, relationto aseptic treatment,
541
Esmarch, aseptic treatment in war,
125
— in'igator, 273
• — on use of iced water, 841
— statistics, 396
Eucalj'ptus oil, aseptic use of, 140, 591
- — ointment, 141
Excision of joints, aseptic dressing of,
107
Exhaustion, deaths from, 554
Exostosis, aseptic treatment of, 503
TpABROXT on fermentation, 3
■-*- Fallooiug on healing under a crust,
294
Eaurc on crust formation, 338
Femur, compound fractures of. See
Compound fractures.
Fermentation, alcolujlic, 209
• — always due to particles coming from
without, 50
— and eremacausis, 9
— Jicrt on, 220
— of blood, 33
boiled ('g£i- albumen, 14, 15, 22
milk, 14, 15, 20. 22, 25
animal tissues, 14, 15, 22, 24
substances. 14, 22, 24, 29
—urine, 24, 26
■ — buiyric, 212
- — cause of, 51
— causes not gaseous, 50
— Cazenciirt! and IJvoth on, 37, 218
— chemical, 2
— definition of, 1
— gaseous theory of, 4
— in wounds, is it prevented by the
aseptic method ? 226, 366
relations of aiitis('ptic surgery
to, 366
— lactic, 214
— Lvinairc on, 218, 353
GAY
Fermentation, lAeiig on, 9, 197, 208
— particulate theory of, 1
— Pasteur's theory of, 223
^— pigment, 212
— prevention of, 51
— putrefactive, 218
— relation of micro-organisms to, 205
— summary of views on, 17
— of tissues in the living body, 50
— of unboiled animal tissues, 44
egg albumen, 42
— grape juice, 30
milk, 37
substances, 30
urine, 36
vegetable tissues, 44
viscous, 214
vital, 2, 206
F'erments, theories of actions of, 205
Ferrier and Yco's experiments on mon-
key, 567
Fiorarcnti, balsam of, 347
FiHcher, E., on micro-organisms in
wounds. 228
— //., on use of alumina acetate, 363
Fooli on immersion, 344
Forceps, sinus, 79
Fore-arm, compound fractures of. See
Compound fractures.
Fractures, compound. .See Compound
fractures.
Fraenckcl and Volkniann.'s septic re-
sults of compound fracture, 511
Franldand on Bastian's experiments,
189
Fritm on water dressing, 316
GANGRENE, aseptic treatment of,
117
Gaseous tlieory of fermentation, 4
Gauze, carbolic, bandage, 89
general dressing, 89
loo^e, 89
Miinnich, 362
use in deep dressing, 88
— carbolised, preparation of (Lister's),
61
(Von r.run's), 63
— dressing, liow to make a, 64
— eucalyptus, 141
- thymol, 139
Ciiiil-fjinotdi- on fermentation, 4
of unl)()iled grape juice, 30
(iaijon on fermentation of unbuiled egg
albumen, 42
INDEX.
609
GEL
Gelatinous degeneration of joints, asep-
tic treatment of, 442
Generation, spontaneous, theories of,
145 et seq.
Gensoul on crust formation, 338, 349
Genu Valgum, MacEwen on, 504
Ogston on, 322
Gibson on removal of loose cartilages,
313
Glycerine, treatment of wounds by, 348
Gossdin on A. Guerin's dressing, 329
Guyraud on subcutaneous surgery, 321
Granulations, absorption by, 268, 407
Grape juice boiled, Gaij-Lussac on, 5
■ unboiled, fermentation of, 30
Gross on subcutaneous osteotomy, 322
— M., on aseptic treatment, 399
Grmthuisen on spontaneous generation,
182
Gschidlen and Trauhe on destraction
of bacteria by healthy tissues, 283
Guard, use of, in aseptic operations, 74
&ueri>is, Aljihrnse, cotton wool treat-
ment, 280, 325, 408
Guerin, Jules, on occlusion, 323, 324,
325
subcutaneous surgery, 320
Gnersant on use of chlorinated soda,
349
Gunshot wounds, aseiJtic treatment of,
123
of bone, results of, 512
-^ ■ joints, 447
Guyot on treatment by incubation, 317
Gvyton on chlorine as a disinfectant,
349
fTACK on absorption by granula-
-*i tions, 2G8, 407
Hands, purification of, 67, 69
Hartley on spontaneous generation, 189
Hawliins, Chas., on occurrence of phage-
da;na, 548
Jlcintzel's statistics of gunshot wounds
of joints, 453
Heister on wound treatment, 302
Helviholtz on fcrrncmtation, 8
Hernia, aseptic dressing of, 105
Heron, early reports of Listerian me-
thod, 134
Hervey on A. Guerin's dressing, 326
Hervienx on use of chlorinated soda,
349
Heterogencsis, theories of, 145
Hewttt, Prescott, on pya;mia in private
practice, 548
Ilingston on use of carbolic acid, 357
HijD joint, aseptic dressing of abscess
of, 104
History of antiseptic surgery, 290
Lister's earlier aseptic methods,
128
Holmes on the gei-m theory, 225
results with cleanliness, 547
— statistics of amputations, 414
compound fracture, 512
Hoppe-Seyler on fermentation of un-
boiled milk, 37
Horse-hair drains, 82
reintroduction of, 83
Hospital, St. Bartholomew's, major am-
putations at, 407
Hueter on aseptic surgery, 39 S
puncture of joints, 447
Hidzinga on spontaneous generation,
181
Humerus, compound fractures of. See
Compound fractures.
Humphrey on the open method, 334
Hunter, J., on bad etfects of air, 308
crust formation, 310, 335
resistance of blood to putrefac-
tion, 284
• wound treatment, 310
Hutchinson, method of using alcohol,
269, 348
— on pya;mia in lower animals, 548
— results with alcohol, 407
Huxley on spontaneous generation, 188
Hydi'ocele, aseptic treatment of, 568
IMMERSION, history and results of.
See Irrigation.
— treatment by, 272
Incubation, treatment by, 317
Infective diseases, definition of, 367
germ theory of, 552
relations of aseptic surgery to,
368, 540
relation of treatment with anti-
septics to, 405
Tnllamuiafion, absence of, in aseptic
wounds, 56(;
Instruments, purificalion of, 67, 69
Intestines, wounds of, aseptic treat-
ment, 115
Iodine, use of, as an antiseptic, 350
Iodoform, 65, 350
Iron perchloride, as a disinfectant, 350
Irrigation, course of wounds treated
by, 587
-- history of, 338
11 R
GIO
INDEX.
Irrigation, its relation to fermentation
in wounds, 366
— treatment b.y, 272
• — and immersion, results of, 3-14, 316,
406
Isamhcrt on irrigation, 3-12
TAW, lower, compound fractures of.
See Compound fractures.
Joints, abscess of, 443
— dangers of wounds of, 296, 30.5, 308,
311, 313, 314, .558
— excision of. See Excision.
— gelatinous degeneration of, 442
— gunshot wounds of, 447
— operations on, 305, 312, 446 et seq.
— healthy, results of aseptic treatment,
426
wounds of, aseptic course of, 421
treatmeni;, 114, 419
Joly on spontaneous generation, 172
Josse on irrigation, 339
Jute, salicylic acid, 138
'jy'EITH, aseptic ovariotomy, 403
-*1- Kcrii, Vincenz von, on wound
treatment, 315
Klcha on micro-organisms in wounds,
228
Koch, method of staining bacteria, 233
— on micrococci, 244
Kraske on gunshot wounds of joints,
447
Krbnleiii, results from open treatment,
410, 586
— statistics of compound fracture, 514
LABARAQUE, Liquor de, 349
Lactic fermentation, 214
Lamaner on irrigation, 339
Lanfranc on immediate union of
wounds, 291
LaiKjcnheek on the permanent water
bath, 342
subcutaneous osteotomy, 322
Laiiltestrr, E. Ray, on spontaneous gen-
eration, 189
Lannelonyue on occlusion, 325
Larrey on wounds of joints, 314
— statistics of operations on joints, 459
jMtta on psoas absce.ss, 306
Laufjier on occlusion, 323
LavdiHicr on fermentation, 3
Le B u: II f on tincture de saponine, 352
LIS
Lccontc and Dc mar quay on carbonic
acid gas, 331
Le Fin-t on dressings with alcohol, 348
Leg, compound fractures of. See Com-
pound fractures.
Leiiiairo on ' coal tar saponine,' 352
fermentation, 218, 353
use of carbolic acid, 354
Lcticvant on operations on joints, 447
results of aseptic treatment, 399
Lcutvenhoeck on yeast, 6
Lex-eilU on removal of loose cartilages,
313
Liehig on feimentation, 9, 197, 208
Ligature of vessels with catgut, 75
Limbs, aseptic dressing of, 101
— - compound fractures of, summary of,
478
Lime, chloride, in wound treatment,
349
Lindpaintner on Nussbaum's statistics,
390
Lister, compound fractures, summary of,
484, 498
— earlier aseptic methods, 128
— on asejJtic treatment in war, 123
use of cotton wool, 141
causes of suppuration, 596
— — crust formation, 128, 337
destruction of bacteria by healthy
tissues, 282
-- — eucalyptus oil, 141
fermentation, 17
— of blood, 35
boiled milk, 20
urine, 20
unboiled milk, 39
— urine, 36
lactic fermentation, 215
organisation of the catgut liga-
ture, 572
— originator of aseptic system, 359
et scq.
— on spontaneous generation, 192, 194,
199
treatment by cleanliness, 544
use of zinc chloride, 349
— operations on joints, summary of,
440
— results of aseptic treatment in Edin-
burgh, 371
Glasgow, 368
London, 382
treatment by antiseptics in
Edinburgh, 376
— summary of spinal abscesses, 536
— table of compound fractures, 466
INDEX.
611
LIS
Lister, table of operations on joints,
421
spinal abscesses, 522
Listerian method, development of, 127
358
materials emploj'ed in, 52
Listerism, definition of, 554
— principles of, 51, 359
lAston on water dressing, 316
Liron and Cazcneiive on fermentation,
218
of unboiled urine, 37
on spontaneous generation,
195, 201
Lomhard on treatment of wounds, 315,
339
Lotion, boracic, 64
— carbolic, 53
Lumbar abscess, Abernethy on, 306
aseptic dressing of, 104
■ results of. See Vertebral abscess.
l{/rAAS on acetate of alumina, 139,
-LfuL 863
MacCormac on gunshot wounds of
joints, 452
statistics of compound fractures,
509
MacEwev, 3Ir., Glasgow statistics, 370
— Dr., absorbable drainage tubes, 84
operations on bones, 504
Mackintosh, use of, in gauze dressing.
03, 90
Mafiatus on wound treatment, 295
JMalgairfne ou effect of air on wounds,
331
irrigation, 341
— statistics of septic treatment, 413
Maisoiincnvc on occlusion, 324
jMalloch, early reports of Listerian
method, 134
Mamma, dressings after operations on,
97
2Iatiiegazza on spontaneous generation,
172
Maijiyr on immersion, 340
McVaifx statistics, 415
Meat, fermentation of. See Animal tis-
sues.
Mi-issner on fermentation of unboiled
animal tissues, 49
Mt'lladcw on aseptic treatment in war,
127
Mcijcr on subcutaneous osteotomj', 322
Micrococci, l')illroth on, 243
— characteristics of, 244
NEL
Micrococci, definition of, 243
— in wounds treated asepticallj-, 243,
247, 256
— Kocli on, 244
— Lister on, 244
— mode of growth of, 244
— relations of, to carbolic acid, 261
— their significance in acute abscess,
255, 596
— Tiegel on, 244
Micro-organisms, are they excluded
from wounds by aseptic treatment 1
227, 454
— Author on relations of, to living body,
205 et seq.
— destruction by healthy tissues, 252,
282
— in acute abscesses, 253, 597
— in chronic abscesses, 253
— in wounds treated asepticallj", 227
ct seq.
— in wounds treated with eucalyptus
gauze, 591
— not present in body in healtli, 248
— relation of, to fermentation, 205
living body, 205 et seq.
— resistance to heat of, 203
— their presence in disease, 250, 597
— relation to spontaneous generation,
145 et seq.
Milk, Appert's method of preserving, 15
— boiled, fermentation of, 14, 15, 20,
22,25
— unboiled, fermentation of, 37, 38, 39,
214
3/ilton on use of potash chlorate, 350
Morfjan, Cmnphell de, on use of zinc
, chloride, 349
Morton's statistics, 371
Mihmieh's carbolic gauze, 362
3[miro, Alex., on bad effects of air, 306
— Hugh, on bad effects of air, 306
Muscles, wounds of, aseptic treatment,
114
Mtisevlv.^ on ammoniacal fermentation
of urhie, 207
Mvsset on spontaneous generation, 172
]\lyotomy, subcutaneous, 319, 320
N^VI, treatment of, 119
JSeck, aseptic dressing of, 96
Necrosis after compound fracture, cause
of, 557
Aeedhavi on spontaneous generation,
146, 149
Ai'Iatoii on dressings with alcohol, 348
R 11 2
612
INDEX.
NEL
Nt'laton on irrigation, 341
Nerves, wounds of, aseptic treatment,
lU
Neuher, absorbable draina<je tubes, 83,
362
— on Esmarch's statistics, 307
permanent aseptic dressing-, 362
Nnidarft'T on crust formation, 271, 279,
335
Listerism, 360
Nivet on irrigation, 340
Nitsshaum. on carbolic acid poisoning,
589
operations on joints, 447
— results of cleanliness, 390, 394, 546
— statistics, 389, 393
OBJECTIONS to aseptic treatment,
588
Occlusion, liistory of, 322
— its relation to fermentation in
wounds, 367
— results of, 323, 407
Ogston on absence of micro-organisms
from healthy body, 250
micro-organisms in abscesses, 253
— wounds treated aseptically,
263
— subcutaneous osteotomy, 322
Ointment, boracic, 64
— eucalyptus, 141
• — salicylic, 65
Oilier on A. Guorin's dressing, 330
Open method of treatment, 276
general course of wounds, 586
history of, 332
relation to fermentation in
wounds, 366
results of 333, 408
in compound fracture, 514
Operations, aseptic, diet after, 576
on healthy joints, 420
• — — results of, 426
— aseptically performed, duties of
dresser in, 72
example of, 67
ligature of vessels, 75
use of guard in, 74
— towel in, 67, 72
— necessary, more fre<|uent]y justifi-
able with Listerigm, 559
— on the weak and diseased, 559
Organisation in blood clot, 568
bone, 571
catgut, 571
dead tissue, Tillmaiivs on, 573
PRI
Organisation in sloughs, 570
Osteitis, aseptic treatment of, 503
Osteo-myelitis, treatment of, 558
Osteotomy, subcutaneous, ' history of,
321
Otius on water treatment, 339
Ovariotomj', aseptic dressing of, 109
"pA GET on operations on joints, 460
-*- pysemia in hospital, 548
results of psoas abscess, 539
Palatius on irrigation, 339
Panas on aseptic treatment, 399
A. Guerin's dressing, 328
' Pansement ouate.' See Wool cotton, A.
Guerin's method.
Pasteur on alcoholic fermentation, 209
— on butyric fermentation, 212
— cultivating fluid, 167
— examination of air by, 165
— on fermentation, 15
of blood, 33
boiled milk, 15
unboiled grape juice, 32
urine, 36
A. Guerin's dressing, 329
SDontaneous generation, 164, 191,
195, 202
— theory of fermentation, 223
Paracelsus's views on wound treatment,
292
Pare, views on wound treatment, 293
Parmanita on wound treatment, 300
Particulate theory of fermentation, 1
PanVs statistics of septic treatment,
414
Pearaon on treatment of psoas abscess,
312
Percy on wound treatment, 315, 339
Perineum, aseptic treatment of abscess
of, 112
Phthisis, operations in, 550
Picard on immersifm, 342, 345
Piechand on wounds of joints, 446
Pigment, formation of, by bacteria, 212
Pins, use of, in gauze dressing, 89
Poisoning with carbolic acid, 588 et seq.
Poncet on A. Gu('rin's dressing, 330
Potash chlorate, 350
Pdit, Perciral, on wound treatment, 304
results of compound fractures,
304
Povchet, examination of air hy, 163
— on spontaneous generation, 153, 168,
196
i Pi-ingle en effects of foul air, 304
INDEX.
613
PRO
Protective, errors in use of, 87
— preparation of, 60
— use in aseptic dressing, 87
Psoas abscess, asejjtic course of, 519
dressing of, 101
early incision of, 519
probabilities of putrefaction in,
537
results of, 305, 30fi, 312, 517
situation of incision, 102, 517
Pupier on immersion, 346
Purification of hands, 67, 69
instruments, 67, 69
recent wounds, 112
septic wounds, 93, 114
skin, 67, 68
Putrefaction, definition of, 1
— dangers of, 551
— eradication of, in compound frac-
tures, 478
— of pus, Bocrliaare on dangers of, 301
— theories of. See Fermentation.
Putrefactive fermentation, 218
Pyaimia in good hygienic conditions,
548
— relations to fermentation in woimds,
550
~DANKE on micro-organisms in asep-
-*^ tic wounds, 227
RenaxCd on use of anti.septics, 351
Rest, MagatuB on, 295
— mechanical, as an antiseptic method
of treatment, 281
— llie fundamental principle of wound
treatment 596
llosults of antiseptic surgery. See Anti-
septic surgery.
aseptic treatment. See Aseptic.
— general aseptic, summary of, 417
— of A. Guerin's dressing. See Wool
cotton.
irrigation. See Irrigation.
occlusion. See Occlusion.
open method. See Open method.
treatment by antiseptics. See
Antiseptics.
water bath. See Water bath.
Retropharyngeal abscess, aseptic treat-
ment of, 110
Rpyher on aseptic treatment in war,
• 126
gunshot wounds of bone, 512
joints, 448
Syme's statistics, 382
— results in war, 401
SCH
Richter on wound treatment, 308
Ricord on treatment of varicose veins,
319
Roberts on fermentation, 22
of blood, 35
boiled animal Tissues, 22
■ — egg albumen, 22
milk. 22
unboiled egg albumen, 43
grape juice, 32
milk, 38
■ urine, 37
vegetable tissues, 44
spontaneous generation, 181, 191,
192, 195
Rochard on dressings witli alcohol, 348
occlusion, 323
water dressing, 316
Rogeniig's applications to wounds, 291
Ruse's open method of treatment, 278
QALICYLIC acid, aseptic use of, 136
O cream, 65, 89
dressings with, 138
— — jute, 137
lotion, 138
ointment, preparation of, 65
— uses of, 117, 270
results of treatment with, 404
wool, 137
Sanderson, Jas., on resistance of seeds to
heat, 203
Sanitas, 271
Saponine, tincture of, 352
Saprajmia, definition of, 367
Saconj on causes of pyemia, 650
treatment by cleanliness, 542
— results witli cleanliness, 545
— statistics, 414
Saxtorph's results of operations on
joints, 446
— statistics, 396
Scabbing, healing hy, 279
Scalp, aseptic dressing of, 96
Scars not adherent after aseptic ampu-
tation, 568
ScJude, comparative statistics, 399
— on wounds of joints, 444
— statistics of compound fractures, 508
Schroeder on fermentation, 14, 15
spontaneous generation, 152
— and Ditsch on fermentation, 12
spontaneous generation,
1.52
Schrorter on pigment bacteria, 212
614
INDEX.
SCH
SeJnVler on micro-organisms in wounds,
228
Schnlz on encalyptus oil, 140
Sehiilzc, experiments on spontaneous
generation, 8, 149
ScJtwann on fermentation, 6
spontaneous generation, 151
Scrotum, aseptic dressing of wounds of,
105
Septic, definition of term, 1
— derivation of term, 1
— cases, table of temperature charts,
584
— treatment, results of, 399, 402, 413
— wounds, purification of, 93
temperature after, 581
Silk, carbolised, preparation of, 60
preservation, 60
Silver sutures as an antiseptic means, 286
— wire as stitches, 86
Sim2?so)i, Sir Jas., on Listerism, 360
Sinus forceps, 79
— putrid, treatment of, 116
Skin, purification of, 67, 68
Skull, compound fractures of, aseptic
treatment of. 115
— results of. See Compound fractures.
Sloughs, organisation in, 570
Smith on irrigation, 339
Socin on results of aseptic treatment,
395
Soda, chlorinated, as an antiseptic, 269,
349
Sjiallanzani on spontaneous generation,
149
Spence, compound fractures, 502
— on operations on joints, 460
— results with cleanliness, 545
— statistics, 378
Spinal abscess, a test of skill in aseptic
treatment, 539
recumbent position in, 111
results of, 517
want of statistics of, 539
Sponges, purification and preservation
■ of, 64
— use of, in dressings, 122
Spontaneous generation, theories of, 145
et scq.
Spoons, Volkmann's sharp, 116
Spray, carbolic acid, experiments test-
ing efficacy of, as germicide, 26, 258
— how to dispense with, 120
— errors in use of, 74
— objections to necessity' for, 363
— one of tlie least necessary precau-
tion.s, 73, 364, 594
Spray, use of, 70
— Ijroducers, hand, 54
steam, 56
Statistics of aseptic treatment, 368 et
seq.
Stimson on efficacy of carbolic spray,
258
Stitching of aseptic wounds, 85
Stitches, button, 85
— of coaptation, 86
relaxation, 86
— removal of, 86
Strapping of aseptic wounds, 86
Stromeyer on immersion, 342
subcutaneous surgery, 320
Subcutaneoiis surgery, 144, 318
Sulphurous acid as an antiseptic, 269
Summary of views on fermentation, 1 1
Suppuration, causes of, 596
— not always due to micro-organisms,
596
Surgerj'-, aseptic, definition of, 51
materials employed in, 52
principles of, 51, 52
— subcutaneous, 144, 318
Syme, method of wound treatment, 386
— on subcutaneous surgerj-, 320
— statistics, 382
Synovitis, aseptic treatment of, results,
442
TEMPERATURE after aseptic opera-
tions, 576
comi^ound fracture, 463
septic wounds, 581
wounds of joints, 421
— charts after compound fractures
(accidentaP, 482, 500
— opening psoas abscess, 534
wounds of joints, 438
of aseptic cases, 585
septic cases, 584
— curve septic, 580
— during tension in a wound, 577
— in carbolic acid poisoning, 589
Tendons, wounds of, aseiDtic treatment,
114, 561
Tenotomj', subcutaneous, 319, 561
Tension, elevation of temperature dur-
ing, 577
— theory of elevation of temperature
during, 579
Ti('(icl on micrococci, 244
Tillmamn on organisation of dead
tissue, 573
IXIJUX.
G15
TIS
Tissues, unboiled animal, fenuentation
of. See Animal tissues.
vegetable, Ruhertx on fermenta-
tion of, i-i
TJieden on wound treatment, 308
Thenard on fermentation, 4
Theories of action of ferments, 205
fermentation. See Fermentation.
spontaneous generation. See
Spontaneous generation.
Tkitrscli on salicylic acid dressings, 136
— results with salicylic acid, 404
Thorax, wounds of, aseptic treatment,
115
Thornton, aseptic dressing in ovari-
otomy, 109
— on aseptic ovariotomy, 402
Thymol, aseptic use of, 139
— treatment with, results, 404
Tiegel and Billroth on fermentation of
unboiled animal tissues, 44
Towel carbolised, use of, in aseptic
operations, 67, 72
Trawhe and Gsoheidleii on destruction
of bacteria bj'' healthy tissues, 283
Treatment, aseptic. See Aseptic.
— by antiseptics. See Antiseptics.
— of dissection wound, 119
neevi, 119
putrid sinuses, 116
varicose veins, 119
Trendelenburg on operating without the
spray, 363, 595
Tytidall on fermentation, 23
spontaneous generation, 192, 203
— use of condensed beam of light by,
17
ULCER, purification of, 93
— treatment of, with boracic acid,
93
Unboiled substances, fermentation of,
30
Unrest, causes of, 596
Vre on fernientation, 8
Urine, boiled, 20, 24
— unboiled, fermentation of, 36
'TZALETTI'J on immersion, 345
'^ Van der Broeck on fermentation
of blood, 33
■ unboiled egg albu-
men, 42
grape juice, 31
urine, 36
WOU
Van der Broeck on spontaneous genera-
tion, 195
Varicocele, Bicord on, 321
Vegetable tissues, unboiled, Boherts on
fermentation of, 44
Veins, vari ;ose, treatment of, 119, 319,
321
Velpeau on eiiects of air on wounds,
331
— on use of coal tar, 351
iodine, 350
Ventilation as an antiseptic means, 287
— in treatment of wounds, 549
— of wounds, Boiiisson on, 279
Verneuil on A. Guerin's dressing, 329
Vezin and Bartsclters open method of
treatment, 277, 332
Vicary on wound treatment, 294
Vigo, De, on treatment of wounds, 292
Villars, Col de, on wound treatment,
301
Viscous fermentation, 214
Vivisection, advantages of Listerism in,
567
Volkmann and Fraenchel, septic results
of compound fractures, 511
— on aseptic fever, 581
— results with cleanliness, 385, 405,
545
— sharp spoons, 116
— statistics, 385
of compound fracture, 506
wounds of joints, 443
TI/AITZ on Esmarch's statistics, 396
Walther, F«/i, on water dressing,
316
Warm bath. See History of Irrigation.
War, aseptic treatment in, 123
— results of aseptic treatment in, 401,
448, 512
Water dressing. See Dressing.
IVcUk, Sjjcneer, on aseptic ovariotomy
403
Wiseman, treatment of wounds, 296
Wood, John, on advantages of aseptic
treatment, 559, 561
use of carbolic acid, 357
Wool, cotton, aseptic use of, 1 4 1
A. Guerin's method, 280, 325
results of, 327, 408
bacteria under, 329, 330
salicylic acid, 137
Wound treatment, fundamental prin-
ciples of, 596
history up to 1867, 357
610
INDUX.
Wounds, ai-cp1ic. (See Af-o) tic.
outline of course of, 5(J(i
— contused, aseptic treatment of, IIH
— dissection, aseptic treatment of, 1 19
— gunshot, aseptic treatment of, 128
— micro - organisms in. See Micro-
organisms.
— of abdomen, 115
intestine, lln
joints, aseptic treatment of, Jl-J,
419
gunshot, 447
results of, 422
muscles, 114
nerves, aseptic treatment, 114
tendons, ase^Dtic treatment of, 114
— thorax, 115
^ produced accident ally, aseptic treat-
ment of, 112
Wounds, septic, purification of, 93, 114
W'iirtz, bad effects of air on wounds,
294
Wpnan, Jcffrii'S, on spontaneous gene-
ration, 1 72, 203
— Morrill, on spontaneous generation,
175
YEAST-PLANT in alcoholic fermen-
tation. 209
Yeo's experiment s on monkeys, 567
ZEIS on immersion, 345
Zinc chloride, C5, 116, 268, 271,
349
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